Greene Sandra B, Williams C E, Pierson S, Hansen R A, Carey T S
Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599-7590, USA.
Qual Saf Health Care. 2010 Jun;19(3):218-22. doi: 10.1136/qshc.2008.031260. Epub 2010 Feb 1.
Legislation enacted in the US State of North Carolina in 2003 requires all licenced nursing homes to report all medication errors. In 2007, nursing homes were encouraged to voluntarily convert from aggregate reporting to a new online system where they reported each individual error.
A new optional web-based reporting tool was made available to all 393 North Carolina nursing homes to submit error reports for each distinct medication error as they occurred during the year.
A total of 5823 medication error reports were submitted by 203 sites (52%) using the new system during the reporting year, a median of 18 error reports per site. Of the 5823 error reports, 612 (10.5%) were categorised as serious. Serious errors were more likely to be caused by drugs given to the wrong patient (RR 4.39, CI 3.7 to 5.2), lab-work error (RR 2.40, CI 1.4 to 4.0), wrong product given (RR 2.22, CI 1.8 to 2.8) and medication overdoses (RR 1.49, 1.2 to 1.8). Serious errors were more likely to occur on second shift (RR 1.32, 1.1 to 1.5). Common medications that are involved in the most serious errors include warfarin (RR 2.58, CI 2.09 to 3.18) and insulin (RR 2.35, CI 1.86 to 2.97), and oxycodone combinations (RR 1.48, CI 1.07 to 2.06).
Data collected from a nursing home medication error system can provide helpful information on serious errors that can be used to focus patient safety efforts to reduce harm. This improved information will be useful in nursing homes for continuous quality improvement efforts.
美国北卡罗来纳州2003年颁布的法规要求所有持牌疗养院报告所有用药错误。2007年，鼓励疗养院自愿从汇总报告转换为新的在线系统，在该系统中报告每起单独的错误。
一个新的基于网络的可选报告工具提供给北卡罗来纳州的所有393家疗养院，用于提交当年发生的每起不同用药错误的错误报告。
在报告年度，共有203个机构（52%）使用新系统提交了5823份用药错误报告，每个机构的错误报告中位数为18份。在5823份错误报告中，612份（10.5%）被归类为严重错误。严重错误更可能由以下原因导致：给错患者用药（相对危险度4.39，可信区间3.7至5.2）、检验工作错误（相对危险度2.40，可信区间1.4至4.0）、给错药品（相对危险度2.22，可信区间1.8至2.8）和用药过量（相对危险度1.49，1.2至1.8）。严重错误更可能发生在中班（相对危险度1.32，1.1至1.5）。涉及最严重错误的常见药物包括华法林（相对危险度2.58，可信区间2.09至3.18）、胰岛素（相对危险度2.35，可信区间1.86至2.97）以及羟考酮复方制剂（相对危险度1.48，可信区间1.07至2.06）。
从疗养院用药错误系统收集的数据可为严重错误提供有用信息，可用于集中患者安全工作以减少伤害。这些改进后的信息将有助于疗养院持续进行质量改进工作。
