국내 급성기 의료기관 고위험 의약품 목록 도출

Abstract

Background: High-alert medications (HAMs) are medications that bear a heightened risk of causing significant patient harm if usedin error. To facilitate safe use of HAMs, identifying specific HAM lists for clinical setting is necessary. We aimed to develop thenational level HAM list for acute care setting. Methods: We used three-step process. First, we compiled the pre-existing lists referringHAMs. Second, we analyzed medication related incidents reported from national patient safety incident report data and adverseevents indicating medication errors from the Korea Adverse Event Reporting System (KAERS).We also surveyed the assistant staffsto support patient safety tasks and pharmacist in charge of medication safety in acute care hospital. From findings from analysis andsurvey results we created additional candidate list of HAMs. Third, we derived the final list for HAMs in acute care settings throughexpert panel surveys. Results: From pre-existing HAM list, preliminary list consisting of 42 medication class/ingredients wasderived. Eight assistant staff to support patient safety tasks and 39 pharmacists in charge of medication safety responded to thesurvey. Additional 44 medication were listed from national patient safety incident report data, KAERS data and commonmedications involved in prescribing errors and dispensing errors from survey data. A list of mandatory and optional HAMsconsisting of 10 and 6 medication classes, respectively, was developed by consensus of the expert group. Conclusion: We developednational level HAM list for Korean acute care setting from pre-existing lists, analyzing medication error data, survey and expertpanel consensus.