Hosp Health Netw. 2003 Aug;77(8):21-2.
What is it they say about the best-laid plans? They often go awry. It's the same with initiatives to make drug delivery in hospitals safer. An organization can analyze its procedures with the most sophisticated methods and squeeze out every possible chance for error, but the new design will mold with disuse if momentum is lost. There are many ways for an innovation to get derailed: lost enthusiasm, personnel changes, budget cuts. As they mature in the safety process, organizations have to be flexible but also stay firm in maintaining medication safety as a top priority. Keep safety initiatives alive by involving staff, "hardwiring" changes into the system and monitoring their progress well into the future.
人们常说的精心规划是怎么回事呢？它们往往会出岔子。医院中旨在提高药物输送安全性的举措也是如此。一个组织可以用最精密的方法分析其流程，排除每一个可能的出错机会，但如果失去动力，新设计就会因无人使用而变形走样。创新有很多种可能脱轨的方式：热情消退、人员变动、预算削减。在安全流程走向成熟的过程中，各组织既要保持灵活，又要坚定地将药物安全作为首要任务。通过让员工参与进来、将变革“固化”到系统中以及长期监测进展情况，来保持安全举措的活力。
