Systems analysis of adverse drug events. ADE Prevention Study Group.
Systems analysis of adverse drug events. ADE Prevention Study Group.
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DOI：
10.1001/jama.274.1.35
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发表时间：
1995-07
期刊：
影响因子：
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通讯作者：
L. Leape;D. Bates;D. Cullen;J. Cooper;H. Demonaco;T. Gallivan;R. Hallisey;J. Ives;N. Laird;G. Laffel
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文献类型：
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作者：
L. Leape;D. Bates;D. Cullen;J. Cooper;H. Demonaco;T. Gallivan;R. Hallisey;J. Ives;N. Laird;G. Laffel
目的识别和评价导致药品不良事件（ADE）和潜在ADE的系统故障。设计前瞻性队列研究事件的系统分析。参与者在6个月内，在两个三级保健医院的11个医疗和外科单位的所有入院。主要结局指标：错误、近端原因和系统故障。方法通过对相关人员的访谈发现错误。由医生、护士、药剂师和系统分析师组成的多学科团队根据近端原因和潜在系统故障对错误进行分类。结果在此期间，334个错误被检测为264个可预防的ADE和潜在的ADE的原因。16个主要系统故障被确定为错误的根本原因。最常见的系统故障是药物知识的传播，特别是对医生，占334个错误的29%。患者信息的可用性不足，如实验室检查结果，与18%的错误有关。七个系统故障占错误的78%;所有这些都可以通过更好的信息系统来改善。结论：医院工作人员愿意参与药物使用错误的检测和调查，并能够识别潜在的系统故障。最常见的缺陷是传播药物知识和在需要时随时提供药物和患者信息的系统。为改善药物和患者数据的传播和显示而进行的系统改革应减少药物使用中的错误。
OBJECTIVE To identify and evaluate the systems failures that underlie errors causing adverse drug events (ADEs) and potential ADEs. DESIGN Systems analysis of events from a prospective cohort study. PARTICIPANTS All admissions to 11 medical and surgical units in two tertiary care hospitals over a 6-month period. MAIN OUTCOME MEASURES Errors, proximal causes, and systems failures. METHODS Errors were detected by interviews of those involved. Errors were classified according to proximal cause and underlying systems failure by multidisciplinary teams of physicians, nurses, pharmacists, and systems analysts. RESULTS During this period, 334 errors were detected as the causes of 264 preventable ADEs and potential ADEs. Sixteen major systems failures were identified as the underlying causes of the errors. The most common systems failure was in the dissemination of drug knowledge, particularly to physicians, accounting for 29% of the 334 errors. Inadequate availability of patient information, such as the results of laboratory tests, was associated with 18% of errors. Seven systems failures accounted for 78% of the errors; all could be improved by better information systems. CONCLUSIONS Hospital personnel willingly participated in the detection and investigation of drug use errors and were able to identify underlying systems failures. The most common defects were in systems to disseminate knowledge about drugs and to make drug and patient information readily accessible at the time it is needed. Systems changes to improve dissemination and display of drug and patient data should make errors in the use of drugs less likely.