巴基斯坦卡拉奇一家三级护理大学医院对用药差错进行跟踪和报告的系统方法。
A systematic approach of tracking and reporting medication errors at a tertiary care university hospital, Karachi, Pakistan.
机构信息
Division of Nursing Services.
出版信息
Ther Clin Risk Manag. 2008 Aug;4(4):673-9. doi: 10.2147/tcrm.s2646.
INTRODUCTION
Administering medication is one of the high risk areas for any health professional. It is a multidisciplinary process, which begins with the doctor's prescription, followed by review and provision by a pharmacist, and ends with preparation and administration by a nurse. Several studies have highlighted a high medication incident rate at several healthcare institutions.
METHODS
Our study design was exploratory and evaluative and used methodological triangulation. Sample size was of two types. First, a convenient sample of 1000 medication dosages to estimate the medication error (95% CI). We took another sample from subjects involved in medication usage processes such as physicians, nurses, pharmacists, and patients. Two sets of instruments were designed via extensive literature review: a medication tracking error form and a focus group interview questionnaire.
RESULTS
Our study findings revealed 100% compliance with a computerized physician order entry (CPOE) system by physicians, nurses, and pharmacists. The main error rate was 5.5% and pharmacists contributed an higher error rate of 2.6% followed by nurses (1.1%) and physicians (1%). Major areas for improvement in error rates were identified: delay in medication delivery, lab results reviewed electronically before prescription, dispension, and administration.
简介
给药是任何医疗保健专业人员的高风险领域之一。这是一个多学科的过程，从医生的处方开始，由药剂师进行审查和提供，最后由护士进行准备和给药。几项研究强调了许多医疗机构的高用药事件发生率。
方法
我们的研究设计是探索性和评估性的，并使用了方法学三角测量。样本量有两种类型。首先，我们对 1000 种药物剂量进行了方便抽样，以估计用药错误（95%CI）。我们从参与用药过程的受试者中抽取了另一组样本，如医生、护士、药剂师和患者。通过广泛的文献回顾设计了两套工具：用药跟踪错误表和焦点小组访谈问卷。
结果
我们的研究结果显示，医生、护士和药剂师 100%遵守了计算机化医嘱输入（CPOE）系统。主要错误率为 5.5%，药剂师的错误率较高，为 2.6%，其次是护士（1.1%）和医生（1%）。确定了提高错误率的主要领域：药物延迟交付、处方前电子审查实验室结果、配药和给药。
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