Di Denia Patrizio, Mingazzini Annella, Guglielmi Vilma, Adamo Christian, Rolli Maurizia, Zanotti Enrichetta, Caroli Giuseppe, Baldi Riccardo
Direzione sanitaria Istituti Ortopedici Rizzoli di Bologna.
Ig Sanita Pubbl. 2007 Jan-Feb;63(1):31-44.
Medication errors occur frequently in many clinical settings. Various studies have highlighted that, together with adverse drug events, they represent one of the major causes of adverse events occurring in hospitals. The aim of this study was to perform a detailed retrospective medical record review in order to investigate the incidence of medication errors occurring in the prescription and transcription phases of the medication use process. Overall, 56 medical records were reviewed to determine the incidence of incomplete or incorrect prescriptions and incorrect transcription by nurses of the original medication order. The findings highlight the need to improve medication safety, in particular at the time of prescription and transcription of orders. The study also confirms that the retrospective review of medical records is an effective method for identifying certain types of medication errors that occur during the prescription and transcription phases. However, this type of review is complex and too costly to be used routinely, for continuous monitoring, in clinical practice.
用药错误在许多临床环境中频繁发生。各种研究都强调,与药物不良事件一起,它们是医院中不良事件的主要原因之一。本研究的目的是进行详细的回顾性病历审查,以调查用药过程中处方和转录阶段发生用药错误的发生率。总体而言,审查了56份病历,以确定不完整或不正确处方的发生率以及护士对原始用药医嘱的转录错误。研究结果凸显了提高用药安全性的必要性,尤其是在医嘱处方和转录时。该研究还证实,回顾性病历审查是识别处方和转录阶段发生的某些类型用药错误的有效方法。然而,这种审查很复杂,成本太高,无法在临床实践中常规用于持续监测。