Goldspiel B R, DeChristoforo R, Daniels C E
National Institutes of Health Clinical Center, Pharmacy Department, Bldg. 10, Room 1N-257, MSC 1196, Bethesda, MD 20892-1196, USA.
Am J Health Syst Pharm. 2000 Dec 15;57 Suppl 4:S4-9. doi: 10.1093/ajhp/57.suppl_4.S4.
A comprehensive, interdisciplinary approach for reducing the number of chemotherapy-related medication errors at the National Institutes of Health Clinical Center, where approximately 8500 doses of chemotherapy agents are dispensed annually, is described. Heightened awareness of the seriousness of chemotherapy-related medication errors prompted formation of an interdisciplinary task force in June 1995 to analyze and improve the hospital's system for ordering, checking, processing, and administering cancer chemotherapy agents. Problems were analyzed and rectified in accordance with the hospital's plan-do-check-act performance-improvement model. Performance monitors for the improvements included a system to record and categorize all chemotherapy-related prescribing errors and a hospital-wide occurrence-reporting system. The task force identified seven major categories in which improvements were needed: protocol development, computer-system enhancements, dose verification, information access, education for health care practitioners, error follow-up, and infusion pumps. Despite the Clinical Center's good safety-net system, 23 modifications were made to the existing system through December 1999. These changes resulted in an overall 23% decrease in prescribing errors and a 53% decrease in serious prescribing errors. The task force membership was recently broadened to include representatives of additional departments where chemotherapy agents are used, and this group recommended more than 20 additional system changes. The changes are being implemented, and their effect on reducing the number of chemotherapy-related errors will be measured. The continuous-improvement process used prospectively by the task force helps ensure that safe chemotherapy practices are instituted uniformly throughout the hospital.
本文描述了一种全面的跨学科方法，用于减少美国国立卫生研究院临床中心与化疗相关的用药错误数量。该中心每年大约发放8500剂化疗药物。对与化疗相关用药错误严重性的更高认识促使在1995年6月成立了一个跨学科特别工作组，以分析和改进医院订购、核对、处理和施用癌症化疗药物的系统。根据医院的计划-执行-检查-行动绩效改进模型对问题进行了分析和纠正。改进的绩效监测指标包括一个记录和分类所有与化疗相关的处方错误的系统以及一个全院范围的事件报告系统。特别工作组确定了七个需要改进的主要类别：方案制定、计算机系统增强、剂量核实、信息获取、医护人员教育、错误跟进和输液泵。尽管临床中心有良好的安全保障系统，但到1999年12月，对现有系统进行了23项修改。这些改变使处方错误总体减少了23%，严重处方错误减少了53%。特别工作组的成员最近扩大到包括使用化疗药物的其他部门的代表，该小组又建议了20多项系统变更。这些变更正在实施，将衡量其对减少与化疗相关错误数量的影响。特别工作组前瞻性地使用的持续改进过程有助于确保在全院统一建立安全的化疗操作规范。
