약학회지

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Table. 1.

Table. 1.

Preliminary list derived from pre-existing high-alert medication lists and patient safety reporting data in community/primary care settingsa

ATC level 2 Medications Pre-existing list Patients incidents from KOPS Patients incidents from KPA
ISMP WHO Japanb Koreac Total (n=182) Harm (n=9) Total (n=8028) Harm (n=255)
A10 Insulins O O O O 2 0 10 1
Sulfonylurea - - O - 2 0 32 9
B01 Anticoagulants, oral O O O - 0 0 4 1
Warfarin O O O O 0 0 22 17
Low molecular weight heparin O O O - 0 0 0 0
L01 Chemotherapeutic agents, oral O O O O 0 0 6 4
L04 Immunosuppressant, oral O - O O 1 0 31 8
Immunosuppressant, parenteral O - O O 0 0 0 0
N02 Opioid analgesics, oral/patch (excluding tramadol) O O O O 0 0 14 10
N03 Carbamazepine O - O - 0 0 1 1
Lamotrigine O - - 0 0 3 0
Phenytoin O - O - 0 0 1 0
Valproate O - O O 0 0 6 1
N05 Benzodiazepines, oral (including clonazepam) - O O - 4 0 97 8
Chloral hydrate O - - O 0 0 0 0
Others Pediatric liquid medicines for requiring measurementd O - - - N/A N/A N/A N/A
Medicines contraindicated during pregnancy (bosentan, isotretinoin) O - - O 0 0 20 2
Medications added from data analysis of KOPS and KPAe
A02 Lafutidine - - - - 1 1 52 0
B01 Acetylsalicylic acid - - - - 4 0 38 5
C10 Atorvastatin - - - - 5 0 51 4
H03 Levothyroxine sodium - - - - 3 0 38 14
M01 Naproxen - - - - 3 0 32 4
M01 Ibuprofen - - - - 1 1 46 0
M01 Dexibuprofen - - - - 3 0 144 4
M01 Loxoprofen - - - - 8 0 939 5
N02 Tramadol and paracetamol - - - - 1 0 64 2
N02 Paracetamol - - - - 3 0 143 3
N03 Pregabalin - - - - 1 0 31 4
N05 Zolpidem - - - - 3 1 23 3
J07 Vaccines - - - - 1 0 4 4

ATC, anatomical therapeutic chemical; ISMP, Institute for Safe Medication Practices; KOPS, Korea Patients Safety Reporting & Learning System;

KPA, Safe Pharm System in Korean Pharmaceutical Association; WHO, World Health Organization.

aAfter analysis of KID-KD, anti-androgen, oxcarbazepine, aripiprazole, teriparatide, telmisartan, levetiracetam, dronedarone, ivabradine, spironolactone, desogestrel and ethinylestradiol, azithromycin, metronidazole, nalidixic acid, posaconazole, voriconazole, phenobarbital, olanzapine were included in a preliminary data, but there was no data on the drugs in KOPS and KPA databases.

bJapan preliminary list of high-alert medication was based on guideline for high-risk drugs from Pharmaceutical Committee in the Japanese Hospital Pharmacist Association.

cKorea preliminary list of high-alert medication was based on guideline of safe management of high-alert medications in community pharmacy practice in 2020 from Korean Pharmaceutical Association.

dAnalysis for pediatric liquid medicines was not possible in the patient safety reporting data, because it was not known whether the medicines were liquid or not.

eCausative medications in the top 25 after analysis of KOPS and KPA data were added.

Yakhak Hoeji 2022;66:249-54 https://doi.org/10.17480/psk.2022.66.5.249
© 2022 Yakhak Hoeji