Mills P D, Neily J, Kinney L M, Bagian J, Weeks W B
VA National Center for Patient Safety, White River Junction, Vermont 05009, USA.
Qual Saf Health Care. 2008 Feb;17(1):37-46. doi: 10.1136/qshc.2006.021816.
Adverse drug events (ADEs) account for considerable patient morbidity and mortality as well as legal, operational and patient care costs. In Veterans Affairs (VA) hospitals in the USA, all serious adverse events and "potential" adverse events are reviewed using root cause analysis (RCA). This study characterised RCA reports associated with ADEs to determine what actions VA RCA teams took to reduce the number or severity of ADEs, and to evaluate which actions were effective in doing so.
Every medication-related RCA submitted to the VA National Center for Patient Safety in the fiscal year 2004 (143 reports), and one medication-related aggregated RCA from each facility (111 reports covering 4834 ADEs) were reviewed and coded. Facilities were interviewed about specifics of their reports and the results of their interventions.
The commonest classes of medication for which ADEs were reported were narcotics, chemotherapy, and diabetic and cardiovascular medications. The most common types of ADE were "wrong dose", "wrong medication", "failed to give medication", and "wrong patient". 993 actions were taken to address these ADEs, the majority (75.7%) of which were reported to be fully implemented. Improvements in equipment and improving clinical care at the bedside were associated with reports of improved outcomes (p = 0.018, and p = 0.017 respectively), and training and education were negatively correlated with reports of improved outcome (p = 0.005). Improving the process of medication order entry through the use of alerts or forcing functions was positively correlated with reports of improved outcomes (p = 0.022). Leadership support and involving staff were associated with higher implementation rates (p = 0.001 and p = 0.010, respectively).
Changes at the bedside and improvement in equipment and computers are effective at reducing ADEs. Well-organised tracking and support from leadership and staff were characteristics of facilities successful at improving outcomes. Training without action was associated with worse outcomes.
药物不良事件（ADEs）导致了相当数量的患者发病和死亡，以及法律、运营和患者护理成本。在美国退伍军人事务部（VA）医院，所有严重不良事件和“潜在”不良事件都采用根本原因分析（RCA）进行审查。本研究对与ADEs相关的RCA报告进行了特征分析，以确定VA RCA团队采取了哪些行动来减少ADEs的数量或严重程度，并评估哪些行动在这方面是有效的。
对2004财年提交给VA国家患者安全中心的每一份与药物相关的RCA（143份报告），以及每个机构的一份与药物相关的汇总RCA（111份报告，涵盖4834起ADEs）进行审查和编码。就各机构报告的具体情况及其干预结果进行了访谈。
报告ADEs的最常见药物类别是麻醉药品、化疗药物以及糖尿病和心血管药物。最常见的ADE类型是“剂量错误”、“用药错误”、“未给药”和“患者错误”。针对这些ADEs采取了993项行动，其中大多数（75.7%）报告已全面实施。设备改进和床边临床护理改善与结果改善报告相关（分别为p = 0.018和p = 0.017），而培训和教育与结果改善报告呈负相关（p = 0.005）。通过使用警报或强制功能改善用药医嘱录入流程与结果改善报告呈正相关（p = 0.022）。领导支持和员工参与与更高的实施率相关（分别为p = 0.001和p = 0.010）。
床边改变以及设备和计算机的改进在减少ADEs方面是有效的。组织良好的跟踪以及领导和员工的支持是成功改善结果的机构的特点。没有行动的培训与更差的结果相关。
