Feldstein Adrianne, Simon Steven R, Schneider Jennifer, Krall Michael, Laferriere Dan, Smith David H, Sittig Dean F, Soumerai Stephen B
Center for Health Research, Kaiser Permanente, Portland, Oregon, USA.
Jt Comm J Qual Saf. 2004 Nov;30(11):602-13. doi: 10.1016/s1549-3741(04)30071-7.
Medication errors and preventable adverse drug events are common, and about half of medication errors occur during medication ordering. This study was designed to develop and evaluate medication safety alerts and processes for educating prescribers about the alerts.
At Kaiser Permanente Northwest, a group-model health maintenance organization where prescribers have used computerized order entry since 1996, qualitative interviews were conducted with 20 primary care prescribers.
Prescribers considered alerts helpful for providing prescribing and preventive health information. More than half the interviewees stated that it would be unwise to let clinicians control or avoid safety alerts. Common frustrations were (1) being delayed by the alert, (2) having difficulty interpreting the alert, and (3) receiving the same alert repeatedly. Most prescribers preferred small-group educational sessions tied to existing meetings and having local physicians conduct education sessions.
The findings were used to design a strategy for introducing and promoting the interventions, modifying the alert text and tools, and focusing the education on how clinicians could use the alerts effectively.
用药错误和可预防的药物不良事件很常见，约一半的用药错误发生在开具医嘱过程中。本研究旨在开发并评估用药安全警报以及针对开处方者开展警报教育的流程。
在西北凯撒医疗集团（Kaiser Permanente Northwest），这是一家团体模式的健康维护组织，自1996年起开处方者就已使用计算机化医嘱录入系统，对20名初级保健开处方者进行了定性访谈。
开处方者认为警报有助于提供处方和预防性健康信息。超过半数的受访者表示，让临床医生控制或避开安全警报是不明智的。常见的困扰包括：（1）被警报耽搁；（2）难以解读警报；（3）反复收到相同的警报。大多数开处方者更喜欢与现有会议相关的小组教育课程，并且希望由当地医生开展教育课程。
研究结果被用于设计一项策略，以引入和推广这些干预措施，修改警报文本和工具，并将教育重点放在临床医生如何有效使用警报上。
