SEVERITY-INDEXED, INCIDENT REPORT-BASED MEDICATION ERROR-REPORTING PROGRAM
SEVERITY-INDEXED, INCIDENT REPORT-BASED MEDICATION ERROR-REPORTING PROGRAM
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DOI：
10.1093/ajhp/48.12.2611
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发表时间：
1991-12-01
期刊：
影响因子：
--
通讯作者：
SCHNEIDER, PJ
中科院分区：
文献类型：
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作者：
HARTWIG, SC;DENGER, SD;SCHNEIDER, PJ
描述了一种用药错误报告程序。（~）大型教学医院的用药错误通过传统的事件报告进行报告。错误的具体信息记录在附加表格中;采集的数据包括错误类型、系统故障点和所涉及的药物类别。还为每个用药错误分配了反映患者结局的严重程度等级。将数据输入到关系数据库中并进行分析。生成的报告显示总体错误率、按严重度等级和药物类别划分的错误分布、错误类型、系统故障点以及与最高严重度等级错误相关的药物类别。1990年1月至12月期间，每月收到的用药错误报告数量从73起至141起不等，而且在这一年中，每月报告的错误数量有所增加。尽管基于事件报告的方法低估了用药错误的实际数量，该计划已有效地确定问题领域和趋势，使质量保证和医疗委员会可以实施措施，以改善药物使用。使用严重程度指数用药错误-一个基于事故报告并通过关系数据库管理的报告程序揭示了一些问题，然后由其他质量保证部门加以解决措施
A medication error-reporting program is described.(~)Medication errors at a large teaching hospital are reported through traditional incident reports. Specific information on the errors is documented on an additional form; data captured include the type of error, system breakdown point, and class of drug involved. A severity ranking that reflects patient outcome is also assigned to each medication error. The data are entered into a relational database and analyzed. Reports are generated that show the overall error rate, the distribution of errors by severity ranking and drug class, and the error types, system breakdown points, and drug classes associated with errors of the highest severity rankings. Between January and December 1990, the number of medication error reports received per month ranged from 73 to 141, and the number of errors reported per month increased during the year. Although the incident report-based method underestimates the actual number of medication errors, the program has been effective in identifying problem areas and trends so that quality assurance and medical committees can implement measures to improve drug use.The use of a severity-indexed medication error-reporting program based on incident reports and managed through a relational database has revealed problems that are then addressed by other quality assurance measures.