Effective strategies to increase reporting of medication errors in hospitals
Effective strategies to increase reporting of medication errors in hospitals
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DOI：
10.1097/00005110-200601000-00009
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发表时间：
2006-01-01
影响因子：
2
通讯作者：
Peters, W
中科院分区：
文献类型：
--
作者：
Force, MV;Deering, L;Peters, W
医院中患者安全的一个主要问题是准确的药物管理。为了改善药物管理过程，护士和药剂师必须报告系统问题。虽然工作人员支持用药错误报告的概念，但他们没有报告错误。对报复、惩罚性行为和职业羞辱的固有恐惧阻止了自我报告用药错误。我们医院的质量改进部门开发、实施和评估了一个名为"生命拯救者"的项目。其目的是建立一种非惩罚性的文化，并增加工作人员的用药错误报告。在一年内，LifeSavers计划将每月的用药错误报告从14份增加到72份。非责备文化的成功发展，用药错误报告导致确定问题的来源和改善用药管理系统。
A major concern for patient safety in hospitals is accurate medication administration. To improve the medication administration process, nurses and pharmacists must report system problems. Although staff supported the concept of medication error reporting, they did not report errors. Inherent fear of retribution, punitive actions, and professional humiliation prevented self-reporting of medication errors. Our hospital's quality improvement department developed, implemented, and evaluated a program called LifeSavers. Its purpose was to build a nonpunitive culture and to increase medication error reporting by staff. In one year, the LifeSavers program increased medication error disclosures from 14 to 72 reports per month. The successful development of a nonblame culture of medication error reporting led to identified sources of problems and improvement of the medication administration system.