Hartmann Hamilton Anne Regitze, Anhøj Jacob, Hellebek Annemarie, Egebart Jonas, Bjørn Brian, Lilja Beth
The Unit for Patient Safety, Capital Region of Denmark, 2650 Hvidore, Denmark.
Stud Health Technol Inform. 2009;148:159-62.
The purpose of this study is to examine how everyday use of the Computerised Physician Order Entry (CPOE) system in the Capital Region of Denmark has led to medication errors. The study is based on clinicians' reporting of patient safety incidents. It was found that the immediate causes of the patient safety incidents primarily relates to a) a mismatch between clinical work routines and the structure of the CPOE system, b) the complexity of the user interface, and c) lack of barriers against commonly occurring, severe errors in some areas of the CPOE system. The following was concluded: A well designed CPOE system should be intuitive, provide barriers against serious mistakes, and make the correct choice an easy one. Furthermore it was concluded that it is important that the CPOE system closely supports accepted clinical work routines and that risk assessment is performed prior to implementing new design or functionality.
本研究的目的是考察丹麦首都地区日常使用计算机化医师医嘱录入（CPOE）系统是如何导致用药错误的。该研究基于临床医生对患者安全事件的报告。结果发现，患者安全事件的直接原因主要与以下几点有关：a）临床工作流程与CPOE系统结构不匹配；b）用户界面的复杂性；c）CPOE系统某些领域缺乏针对常见严重错误的防范措施。得出以下结论：设计良好的CPOE系统应直观，能防范严重错误，并使正确选择变得容易。此外，得出结论认为，CPOE系统紧密支持公认的临床工作流程以及在实施新设计或功能之前进行风险评估很重要。
