拉莫三嗪相关用药错误病例报告文献分析OA

OBJECTIVE:To investigate the contents,clinical manifestations and outcomes of lamotrigine-associated medication errors.METHODS:Relevant databases at home and abroad(up to Sept.20th,2024)were retrieved and the case reports on lamotrigine-associated medication errors were collected.Patient's basic information,content of medication errors,clinical manifestations and outcomes induced by medication errors.Statistical analysis was conducted by using the Excel software.RESULTS:A total of 47 case reports with lamotrigine-associated medication errors were enrolled,including 60 patients.The content of medication errors included dosage(26 cases,43.3%,including excessive initial dosage or rapid dosage increase,and failure to reduce dosage in time after delivery),drug interactions(22 cases,36.7%),variety of drugs(5 cases,8.3%),and patient identity(7 cases,11.7%).There were 59 cases of harmful medication errors(98.3%),mainly involving adverse outcomes in the skin and soft tissue system(such as Stevens-Johnson syndrome and toxic epidermal necrolysis),the nervous system(such as epileptic seizures,dizziness,and tremors),the blood system(such as leukopenia and neutropenia),and the digestive system(such as elevated aminotransferase levels).The main factors of lamotrigine-associated medication errors included pharmaceutical factors(similar drug names)and personnel factors(insufficient knowledge).CONCLUSIONS:The most common types of lamotrigine-associated medication errors are excessive dosage and drug interaction.The adverse outcomes are observed in multiple systems.More attention should be paid to the dosage and interaction of lamotrigine to ensure the medication safety of patients.