Leonard Michael S, Cimino Michael, Shaha Steven, McDougal Sandra, Pilliod Joanne, Brodsky Linda
Center for Pediatric Quality, Women and Children's Hospital of Buffalo, 219 Bryant St, Buffalo, NY 14222, USA.
Pediatrics. 2006 Oct;118(4):e1124-9. doi: 10.1542/peds.2005-3183.
Medication management is a complex, multifaceted system. Prescribing errors occur upstream in the process, and as such, their effects can be perpetuated, and sometimes even exacerbated, in subsequent steps. These errors place patients at risk of adverse drug events. Children, especially young infants, are at particular risk because of their size, unique physiology, and immature ability to metabolize drugs.
The purpose of this study was to reduce the risk of harm to children resulting from prescribing errors.
We sequentially implemented patient safety initiatives over a 1-year time frame at a pediatric tertiary care academic facility. The initiatives included an educational Web site with competency examination, distribution of a personal digital assistant-based standardized dosing reference, a zero-tolerance policy for incomplete or incorrect medication orders, prescriber performance feedback, and presentation of outcome data at citywide grand rounds. A total of 8718 orders were collected and analyzed to assess the impact of these initiatives.
The absolute risk reduction from prescribing errors was 38 per 100 orders, with a relative risk reduction of 49%. Web-based education with point-of-care drug references and a zero-tolerance policy for incomplete or incorrect orders were most effective in decreasing potential adverse drug events. Documentation of appropriate weight-based dosing and indication for therapy increased by 24% and 42%, respectively.
Process-improvement initiatives focusing on prescriber education and behavior modification can reduce the risk of harm to pediatric patients from prescribing errors.
药物管理是一个复杂、多方面的系统。处方错误在流程上游就已出现，因此其影响可能会在后续步骤中持续存在，有时甚至会加剧。这些错误使患者面临药物不良事件的风险。儿童，尤其是幼儿，因其体型、独特的生理机能以及药物代谢能力不成熟而面临特别的风险。
本研究的目的是降低因处方错误给儿童带来伤害的风险。
我们在一家儿科三级护理学术机构，于1年时间内依次实施了患者安全举措。这些举措包括一个带有能力测试的教育网站、分发基于个人数字助理的标准化剂量参考资料、对不完整或错误的用药医嘱实行零容忍政策、向开处方者反馈绩效，以及在全市范围内的大型学术会议上展示结果数据。总共收集并分析了8718条医嘱，以评估这些举措的影响。
处方错误导致的绝对风险降低为每100条医嘱减少38例，相对风险降低49%。基于网络的教育结合即时护理药物参考资料以及对不完整或错误医嘱的零容忍政策，在减少潜在药物不良事件方面最为有效。基于适当体重的剂量记录和治疗指征记录分别增加了24%和42%。
专注于开处方者教育和行为改变的流程改进举措，可以降低因处方错误给儿科患者带来伤害的风险。
