Kirke C
Ir Med J. 2009 Nov-Dec;102(10):339-41.
Medication error and adverse drug reactions occur frequently, leading to a high burden of patient harm in the hospital setting. Many Irish hospitals have established medication safety initiatives, designed to encourage reporting and learning to improve medication use processes and therefore patient safety. Eight Irish hospitals or hospital networks provided data from voluntary medication safety incident and near miss reporting programmes for pooled analysis of events occurring between 1st January 2006 and 30th June 2007. 6179 reports were received in total (mean 772 per hospital; range 96-1855). 95% of reports did not involve patient harm. Forty seven percent of reports related to the prescribing stage of the medication use process, 40% to the administration stage and 9% to the pharmacy dispensing stage. This data is published to increase awareness of this key patient safety issue, to share learning from these incidents and near misses and to encourage a more open patient safety culture.
用药差错和药物不良反应频繁发生,在医院环境中给患者造成了沉重的伤害负担。许多爱尔兰医院已开展用药安全倡议活动,旨在鼓励上报和吸取经验教训,以改进用药流程,从而提高患者安全。八家爱尔兰医院或医院网络提供了来自自愿性用药安全事件及未遂事件上报项目的数据,用于对2006年1月1日至2007年6月30日期间发生的事件进行汇总分析。共收到6179份报告(每家医院平均772份;范围为96 - 1855份)。95%的报告未涉及患者伤害。47%的报告与用药流程的处方阶段有关,40%与给药阶段有关,9%与药房配药阶段有关。公布这些数据是为了提高对这一关键患者安全问题的认识,分享从这些事件和未遂事件中吸取的经验教训,并鼓励营造更开放的患者安全文化。