Stump L S
Department of Pharmacy, Yale-New Haven Hospital, New Haven, CT, USA.
Am J Health Syst Pharm. 2000 Dec 15;57 Suppl 4:S10-7. doi: 10.1093/ajhp/57.suppl_4.S10.
A hospital's change from a traditional, multitiered incident-reporting system for medication errors to a standardized, nonpunitive medication-use variance process is described. After weaknesses were identified in the hospital's system for reporting and evaluating medication errors, a multidisciplinary task force was formed to redesign the hospital's medication error-reporting system. Its guiding principles were as follows: anonymity and freedom from punitive action are essential for increasing the number of reports, rating medication errors facilitates identification of areas for system improvement, potential errors provide valuable insight into the system's vulnerabilities, and timely review of reports enables rapid systematic correction. To support the intended nonpunitive culture, the term medication-use variance was used in lieu of medication error for any unplanned event that deviates from the intended course of prescribing, dispensing, administering, or monitoring medications. A one-page medication-use variance report was developed that prompted the reporter for key data elements, including root causes, patient outcomes, and possible ways to prevent similar incidents. The most difficult decision for the task force was deciding whether the process should be anonymous. After getting the support of the medical-legal counsel and the quality improvement department for an anonymous reporting process, the task force agreed to test it in the department of pharmacy and in three patient units in September 1998. A paper-driven reporting process was selected initially because an electronic system would not be truly anonymous. The number of reports from these units increased compared with historical trends, and for the first time potential errors were reported. The report form was easy to use and improved the interpretation of reports. Despite these positive results, task force members remained divided on the issue of anonymity but ultimately embraced the nonpunitive culture. In the first six months following hospitalwide implementation, the number of events captured increased more than fivefold; it continues to increase. The resulting database serves as a trigger for quality improvement efforts and a measure of their effectiveness. The redesign of the medication error-reporting process served as the impetus for a change in the organizational culture surrounding medication errors.
本文描述了一家医院从传统的多层级用药错误事件报告系统转变为标准化、无惩罚性的用药差异处理流程的过程。在医院的用药错误报告和评估系统中发现薄弱环节后，成立了一个多学科特别工作组，重新设计医院的用药错误报告系统。其指导原则如下：匿名性和免受惩罚对增加报告数量至关重要；对用药错误进行评级有助于确定系统改进的领域；潜在错误能深入了解系统的脆弱性；及时审查报告可实现快速系统纠正。为支持预期的无惩罚文化，对于任何偏离预期的处方、配药、给药或监测药物过程的意外事件，使用“用药差异”一词代替“用药错误”。开发了一份单页的用药差异报告，促使报告者提供关键数据元素，包括根本原因、患者结果以及预防类似事件的可能方法。特别工作组面临的最艰难决定是确定该流程是否应匿名。在获得医疗法律顾问和质量改进部门对匿名报告流程的支持后，特别工作组于1998年9月同意在药房和三个病房进行测试。最初选择纸质报告流程是因为电子系统无法真正匿名。与历史趋势相比，这些病房的报告数量有所增加，并且首次报告了潜在错误。报告表格易于使用，改进了报告的解读。尽管取得了这些积极成果，但特别工作组成员在匿名问题上仍存在分歧，但最终接受了无惩罚文化。在全院实施后的前六个月，捕获的事件数量增加了五倍多，并且仍在继续增加。由此产生的数据库成为质量改进工作的触发因素及其有效性的衡量标准。用药错误报告流程的重新设计推动了围绕用药错误的组织文化变革。
