[The approaches to factors which cause medication error--from the analyses of many near-miss cases related to intravenous medication which nurses experienced].
[The approaches to factors which cause medication error--from the analyses of many near-miss cases related to intravenous medication which nurses experienced].
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用药失误因素探讨——从护士经历的多起静脉用药险情案例分析[J].
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发表时间：
2001
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通讯作者：
H. Kawamura
中科院分区：
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作者：
H. Kawamura
考虑到静脉给药过程的复杂性，系统性思维对于减少用药错误至关重要。分析了2800例“Hiyari-Hatto”病例。结果明确了引起静脉用药差错的8个重要因素。在下文中，我总结了每个因素的系统方法。1.信息沟通失败：手写医嘱难以辨认，口头医嘱和复印不准确导致用药错误。必须制定规则以防止误解。2.硬件设计容易出错：药品包装和标签的外观相似以及输液泵的不良设计会导致错误。制造商应通过抗错误设计来改善人机界面。3.患者姓名与同时进行的外科手术和干预相似：该因素导致患者错误识别。应将自动识别设备引入医疗保健机构。4.任务中途中断：应有效分配医疗工作和业务工作。5.混合程序不准确和混合空间不足：混合程序必须标准化，必须检查工作空间的布局。6.时间压力：工作量和人力之间的不匹配应通过重新考虑要完成的工作来改善。7.缺乏关于高警戒药物的信息：药剂师应该在整个用药过程中发挥更大的作用。8.应届毕业生的知识和技能差：必须开发防止用药错误的培训方法和工具。
Given the complexity of the intravenous medication process, systematic thinking is essential to reduce medication errors. Two thousand eight hundred cases of 'Hiyari-Hatto' were analyzed. Eight important factors which cause intravenous medication error were clarified as a result. In the following I summarize the systematic approach for each factor. 1. Failed communication of information: illegible handwritten orders, and inaccurate verbal orders and copying cause medication error. Rules must be established to prevent miscommunication. 2. Error-prone design of the hardware: Look-alike packaging and labeling of drugs and the poor design of infusion pumps cause errors. The human-hardware interface should be improved by error-resistant design by manufacturers. 3. Patient names similar to simultaneously operating surgical procedures and interventions: This factor causes patient misidentification. Automated identification devices should be introduced into health care settings. 4. Interruption in the middle of tasks: The efficient assignment of medical work and business work should be made. 5. Inaccurate mixing procedure and insufficient mixing space: Mixing procedures must be standardized and the layout of the working space must be examined. 6. Time pressure: Mismatch between workload and manpower should be improved by reconsidering the work to be done. 7. Lack of information about high alert medications: The pharmacist should play a greater role in the medication process overall. 8. Poor knowledge and skill of recent graduates: Training methods and tools to prevent medication errors must be developed.