Harmful Medication Errors Involving Unfractionated and Low-Molecular-Weight Heparin in Three Patient Safety Reporting Programs
Harmful Medication Errors Involving Unfractionated and Low-Molecular-Weight Heparin in Three Patient Safety Reporting Programs
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DOI：
10.1016/s1553-7250(10)36032-6
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发表时间：
2010-05-01
影响因子：
2.3
通讯作者：
Vaida, Allen J.
中科院分区：
文献类型：
--
作者：
Grissinger, Matthew C.;Hicks, Rodney W.;Vaida, Allen J.
背景：医疗差错和不良事件的外部报告使我们能够从他人的差错中学习，以寻求系统级别的改进，从而防止未来的差错。方法：对涉及抗凝剂肝素的报告错误的数据进行审查、比较，并从三个大型患者安全报告计划的数据库中进行汇总--MEDMARX(R)、宾夕法尼亚州患者安全局的患者安全报告系统和大学卫生系统联盟，它们共同代表了2005年超过1,000个报告组织。结果：向这些计划报告了大约300,000个用药错误和差错，以及10,359-平均3.6%(范围，3.1%-5.5%)-涉及肝素产品。涉及患者伤害的肝素相关报告的比例从1.4%到4.9%不等。在有害事件中，用药过程中最常被引用的阶段是给药阶段(56%的错误导致伤害)，其次是处方阶段(19%的错误导致伤害)。讨论：这项研究是这三个大型报告系统首次尝试合并单一临床过程的数据。报告中明显的一致模式，如涉及肝素的所有用药错误的百分比，表明报告程序，至少对于药物错误等常见事件，可能会达到一个回报递减的点，一旦捕获和分析大量类似事件，聚合更多特定类型的报告不会产生额外的洞察力。
Background: External reporting of medical errors and adverse events enables learning from the errors of others in the pursuit of systems-level improvements that can prevent future errors. It is logical to presume that medication errors involving the use of anticoagulants, among the most frequently cited product classes involved in harmful medication errors, would be captured in a variety of patient safety reporting programs.Methods: Data on reported errors involving the anticoagulant heparin were reviewed, compared, and aggregated from the databases of three large patient safety reporting programs-MEDMARX (R), the Pennsylvania Patient Safety Authority's Patient Safety Reporting System, and the University Health System Consortium, together representing more than 1,000 reporting organizations for 2005.Results: Approximately 300,000 medication errors and near misses were reported to the programs, and 10,359-a mean of 3.6% (range, 3.1%-5.5%)-involved heparin products. The proportion of heparin-related reports that involved patient harm ranged from 1.4% to 4.9%. The phase of the medication use process cited most frequently in harmful events was the administration phase (56% of errors leading to harm), followed by the prescribing phase (19% of errors leading to harm).Discussion: This study represents the first attempt by these three large reporting systems to combine data on a single clinical process. The consistent patterns evident in the reports, such as the percentage of all medication errors that involved heparin, suggests that reporting programs, at least for common events such as medication errors, may reach a point of diminishing returns in which aggregating more reports of a certain type yields no additional insight once a large volume of similar events is captured and analyzed.