Patient Safety Division, Alberta Health Services, Calgary, AB, Canada.
Can J Anaesth. 2010 May;57(5):490-9. doi: 10.1007/s12630-010-9274-8. Epub 2010 Feb 9.
In Calgary, each of the three acute-care adult hospitals had different anesthetic medication carts with their own type and layout of anesthetic medications. A number of anesthesiologists moved among the different sites, increasing the potential for medication errors. The objective of this study was to identify the anesthetic medications to include and to determine how they should be grouped and positioned in a standardized anesthesia medication cart drawer.
A standardized list of medications was established. Next, the anesthesia medication cart drawer was filled and photographed, and a jigsaw puzzle was made from the photograph. Anesthesiologists and anesthesia assistants arranged the jigsaw pieces into an ideal drawer. Participants verbalized their rationale for the position of each puzzle piece. Results were collated and analyzed. A mock drawer was developed and reviewed by department members, and minor modifications were made.
A final standardized medication drawer (content and positioning) was developed over 30 months, with agreement from anesthesiologists (n = 12) and anesthesia assistants (n = 3) at the three hospitals. Guidelines for placing each medication in the drawer included grouping them according to order of use, frequency of use, similarity of action, severity of harm from misuse, and lack of similar appearance. A finalized template was used for a standardized drawer and installed in every operating room of the three hospitals.
Implementation of the standardized medication drawer is expected to reduce the likelihood of medication errors. Future research should include testing the clinical implications of this standardization and applying the methodology to other areas.
在卡尔加里，3 家成人急症医院的每个医院都有不同类型和布局的麻醉药物车，许多麻醉师在不同地点之间移动，增加了用药错误的可能性。本研究的目的是确定应包含的麻醉药物，并确定如何将它们分组并放置在标准化的麻醉药物车抽屉中。
建立了标准化的药物清单。接下来，将麻醉药物车抽屉装满并拍照，然后从照片中制作拼图。麻醉师和麻醉助理将拼图块排列成理想的抽屉。参与者口头说明他们对每个拼图块位置的理由。结果进行了整理和分析。开发了一个模拟抽屉，并由部门成员进行了审查和修改。
经过 30 个月的时间，在 3 家医院的 12 名麻醉师和 3 名麻醉助理的共同努力下，最终制定出标准化的药物抽屉（内容和定位）。放置每个药物抽屉的指南包括根据使用顺序、使用频率、作用相似性、误用造成的危害严重程度和缺乏相似外观来分组。使用最终模板为 3 家医院的每个手术室都安装了标准化的抽屉。
预计实施标准化药物抽屉将降低用药错误的可能性。未来的研究应包括测试这种标准化的临床意义，并将该方法应用于其他领域。
