Schneider P J, Hartwig S C
Ohio State University Medical Center, Columbus 43210.
Hosp Pharm. 1994 Mar;29(3):205-6, 208-11.
A severity-indexed medication error reporting system using data from voluntary incident reports has provided enough information to target opportunities for quality improvement. Reports are ranked by severity and categorized by error type, system breakdown, drug category, and nursing unit. Specific reports are generated for review by different quality improvement committees in the hospital. Based on these data and the actions of these quality improvement committees, four problem areas in medication use have been identified. Recommendations for improvements have been made to solve problems with late IV antibiotic doses, narcotic errors, anticoagulant errors and transcription errors. Two of these initiatives have resulted in objective improvement. Two others are being actively pursued to resolve medication related problems.
一个利用自愿上报事件数据的按严重程度分级的用药错误报告系统，已提供了足够信息来确定质量改进的机会。报告按严重程度排序，并按错误类型、系统故障、药物类别和护理单元进行分类。会生成特定报告供医院不同质量改进委员会审查。基于这些数据以及这些质量改进委员会的行动，已确定了用药方面的四个问题领域。已提出改进建议，以解决静脉注射抗生素剂量延迟、麻醉药品错误、抗凝剂错误和抄写错误等问题。其中两项举措已带来客观的改进。另外两项正在积极推进，以解决与用药相关的问题。
