Medication errors in paediatric practice: insights from a continuous quality improvement approach
Medication errors in paediatric practice: insights from a continuous quality improvement approach
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儿科实践中的用药错误：来自持续质量改进方法的见解
DOI：
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发表时间：
1998
影响因子：
3.6
通讯作者：
A. Stuart
中科院分区：
文献类型：
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作者：
D. Wilson;R. McArtney;R. Newcombe;R. McArtney;J. Gracie;C. Kirk;A. Stuart
摘要：目的是评估用药错误的发生率和后果，突出复发性错误的来源，并在实践中进行改革，以防止其复发。采用持续质量改进方法，采用不良事件报告计划进行了一项为期2年的前瞻性队列研究。一个多学科委员会分析了用药错误报告，根据类型（处方、供应或给药）、严重程度（严重或不严重）和临床结局对其进行分类。为减少错误频率，对政策和做法进行了修改。研究期间报告了441例用药错误，其中682例患者住院5315天。在重症监护环境中，错误发生的可能性是七倍以上。医生占错误的72%，当新医生加入轮换时，处方错误增加了一倍。大多数错误（68%）在给药前检测到。24例严重的用药错误没有提前发现，但只有4例有明显的临床后果。排除预防性错误和处方治疗的适当偏离，有117例实际用药错误（1/5.8入院，或1/45住院日）。在该计划的第二年，所有报告的错误、给药错误和严重错误的发生率下降，但处方错误率保持不变。
结论本研究中用药错误发生率较高，但不良后果较少。本研究中使用的非惩罚性、多学科的用药错误方法提高了工作人员的警惕性，突出了复发性错误的来源，并导致药物政策和工作人员培训的变化，从而提高了患者的安全性和护理质量。
Abstract The objective was to assess the incidence and consequences of medication errors, highlight sources of recurrent error and institute changes in practice to prevent their recurrence. Utilising a continuous quality improvement approach, a 2-year prospective cohort study was undertaken using an adverse incident reporting scheme. A multidisciplinary committee analysed medication error reports, classifying them according to type (prescription, supply or administration), severity (serious or not serious) and clinical outcome. Changes in policy and practice were implemented to reduce the frequency of errors. There were 441 reported medication errors in the study period, during which 682 patients were admitted for 5315 inpatient days. Errors were more seven times likely to occur in the intensive care setting. Doctors accounted for 72% of errors and prescription errors doubled when new doctors joined the rotation. Most errors (68%) were detected prior to drug administration. Twenty-four serious medication errors were not detected in advance, but only 4 had overt clinical consequences. Excluding prevented errors and appropriate deviations from prescribed therapy, there were 117 actual medication errors (1/5.8 admissions, or 1/45 inpatient days). During the 2nd year of the scheme, the incidence of all reported errors, administration errors and serious errors fell, but the prescription error rate remained constant.
Conclusions Medication errors occurred commonly in this study, but adverse consequences were rare. The non-punitive, multidisciplinary approach to medication errors utilised in this study increased staff vigilance, highlighted sources of recurrent error, and led to changes in drug policies and staff training, which resulted in improved patient safety and quality of care.