Medication Error Reduction, Technologies & Human Factor

描述（由申请人提供）：技术已用于减少整个用药过程中的用药错误。然而，技术的实施与前瞻性的方法，使用人为因素的技术，以平滑过渡，是不是经常使用。 相反，执行失败和出现新的错误。 给药过程中几乎没有双重检查，新技术可以减少错误。 静脉给药错误直接影响患者，是最严重的给药错误之一。智能IV泵具有预定义的药物剂量限制，其与条形码技术的集成可能是对输注错误的最终防御。本研究旨在评估智能IV泵的实施及其与大型大学医院条形码药物管理系统的集成。这些技术能够减少给药错误，并改变护士和其他最终用户的工作生活。因此，将采用带有预期误差分析的人为因素方法来评价技术和技术变革过程;特别是利用故障模式和影响分析、工作系统分析和技术变革调查来改进执行情况。对Smart IV泵事件日志数据和错误报告的直接观察、调查和纵向评估将提供有关IV泵编程错误以及受变更过程影响的供应商工作和工作生活特征的丰富数据。本研究将为没有药物管理技术的医院提供评估和改变与泵程控错误相关的人为、药物和组织因素的机会。将获得并共享有关智能IV泵实施和与条形码药物管理系统集成相关的技术变更过程的有价值信息，以允许其他医院安全有效地实施这些技术并避免新的错误。

DESCRIPTION (provided by applicant): Technology has been used to decrease medication errors throughout the medication use process. However, implementation of technology with a prospective approach using human factors techniques to smooth the transitions is not routinely used. Instead, failures in implementation and new errors have occurred. The medication administration process has few double checks in the process and new technology is available to decrease errors. Intravenous medication errors directly reach the patient and are among the most serious medication errors. Smart IV pumps have predefined medication dose limits and their integration with bar code technology may be the ultimate defense for infusion errors. This study proposes to evaluate the implementation of Smart IV pumps and their integration with a bar code medication administration system in a large University Hospital. The technologies have the ability to decrease medication administration errors and also change nurses' and other end users' worklife. For that reason, the human factors approach with prospective error analysis will be used to evaluate the technology and technology change process; specifically utilizing failure mode and effects analysis, work system analysis and technology change surveys to improve implementation. Direct observations, surveys and longitudinal assessment of the Smart IV pump event log data and error reports will provide rich data on IV pump programming errors and provider job and worklife characteristics affected by the change process. This study will provide hospitals without medication administration technology opportunities to assess and change human, medication and organizational factors related to pump programming errors. Valuable information will be gained and shared about the technology change process associated with Smart IV pump implementation and integration with a bar code medication administration system to allow other hospitals to safely and effectively implement these technologies and avert new errors.