Causes of prescribing errors in hospital inpatients: a prospective study
Causes of prescribing errors in hospital inpatients: a prospective study
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DOI：
10.1016/s0140-6736(02)08350-2
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发表时间：
2002-04-20
期刊：
影响因子：
168.9
通讯作者：
Barber, N
中科院分区：
文献类型：
--
作者：
Dean, B;Schachter, M;Barber, N
背景为了防止在开药过程中出现差错，我们需要知道为什么会出现差错。用于理解高危行业失误原因的人为失误理论正被用于医疗保健。然而，它们还没有被应用于开出错误的处方，这是伤害患者的一大原因。我们的目的是使用这种方法来调查此类错误的原因。方法英国一家教学医院的药剂师前瞻性地确定了88个潜在的严重处方错误。我们采访了44名开处方的人，并用人为错误理论分析了我们的发现。我们的结果表明，大多数错误是由于注意力疏忽，或者因为处方人没有遵守相关规则而犯的。医生确定了许多风险因素--工作环境、工作量、是否给自己的病人开药、团队内部沟通、身心健康以及缺乏知识。组织因素也被确定，包括培训不足、对处方重要性的认识不高、分级医疗团队以及缺乏对错误的自我意识。为了减少处方错误，医院应该在初级医生开始开处方之前对他们进行药物剂量原则的培训，并在文件中强制执行良好做法。他们还应该创造一种文化，在这种文化中，处方书写被视为重要的，并正式审查药剂师的干预措施、地点安排和初级医生的工作量，并让医生意识到他们可能出错的情况。
Background To prevent errors made during the prescription of drugs, we need to know why they arise. Theories of human error used to understand the causes of mistakes made in high-risk industries are being used in health-care. They have not, however, been applied to prescribing errors, which are a great cause of patient harm. Our aim was to use this approach to investigate the causes of such errors.Methods Pharmacists at a UK teaching hospital prospectively identified 88 potentially serious prescribing errors. We interviewed the prescribers who made 44 of these, and analysed our findings with human error theory.Findings Our results suggest that most mistakes were made because of slips in attention, or because prescribers did not apply relevant rules. Doctors identified many risk factors-work environment, workload, whether or not they were prescribing for their own patient, communication within their team, physical and mental well-being, and lack of knowledge. Organisational factors were also identified, and included inadequate training, low perceived importance of prescribing, a hierarchical medical team, and an absence of self-awareness of errors.Interpretation To reduce prescribing errors, hospitals should train junior doctors in the principles of drug dosing before they start prescribing, and enforce good practice in documentation. They should also create a culture in which prescription writing is seen as important, and formally review interventions made by pharmacists, locum arrangements, and the workload of junior doctors, and make doctors aware of situations in which they are likely to commit errors.