Rickrode Geoffrey A, Williams-Lowe Marva E, Rippe Jane L, Theriault Robert H
Adult Critical Care, Department of Pharmacy, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA.
Am J Health Syst Pharm. 2007 Jun 1;64(11):1197-202. doi: 10.2146/ajhp060166.
The current pharmacy occurrence-reporting system in an institution was reviewed, and an internal procedure that would provide data to improve the medication-use process was developed.
In a rural, 353-bed, tertiary care academic center, the effectiveness of a departmental occurrence-reporting system was determined over a nine-month period to increase occurrence reporting within the pharmacy and allow administrators to identify specific areas for improvement within the medication distribution process. These events were identified according to the number and type of near misses documented by pharmacy staff. The pharmacy staff was asked to complete a survey about the department's current reporting process and what the staff desired in a new occurrence-reporting system. The staff was also surveyed on which steps of the pharmacy's medication distribution process could contribute to the most errors. Initially, a paper-based error-reporting form was developed for all steps of the pharmacy distribution process except pharmacist order entry. Once the paper-based error-reporting form was introduced, the pharmacist order-entry phase of the project was begun. During the evaluation period, 203 pharmacy-dispensing errors were reported to the hospital's error-reporting system. In contrast, 1385 total pharmacy events were documented using the pharmacy's internal occurrence-reporting system. At least 204 of those reported events involved high-alert medications according to the institution's high-alert medications policy.
A pharmacy internal occurrence-reporting system increased staff reporting and identified areas for improvement within the medication distribution process that may not have been recorded by a hospital-based reporting system.
对某机构当前的药房事件报告系统进行审查，并制定一项内部程序，以提供数据来改进用药流程。
在一家拥有353张床位的农村三级医疗学术中心，在九个月的时间里确定了部门事件报告系统的有效性，以增加药房内的事件报告，并使管理人员能够确定用药分发过程中需要改进的具体领域。这些事件是根据药房工作人员记录的险些失误的数量和类型来确定的。药房工作人员被要求完成一项关于部门当前报告流程以及他们对新事件报告系统期望的调查。还对药房用药分发流程的哪些步骤可能导致最多错误对工作人员进行了调查。最初，为药房分发流程的所有步骤（除药剂师订单录入外）制定了纸质错误报告表。一旦引入纸质错误报告表，该项目的药剂师订单录入阶段就开始了。在评估期间，有203起药房配药错误报告给了医院的错误报告系统。相比之下，使用药房内部事件报告系统记录的药房事件总数为1385起。根据该机构的高警示药品政策，这些报告事件中至少有204起涉及高警示药品。
药房内部事件报告系统增加了工作人员的报告，并确定了用药分发过程中可能未被基于医院的报告系统记录的改进领域。
