Centre for Medical and Health Sciences Education, Department of Anaesthesiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
Anaesthesia. 2010 May;65(5):490-9. doi: 10.1111/j.1365-2044.2010.06325.x. Epub 2010 Mar 19.
A safety-orientated system of delivering parenteral anaesthetic drugs was assessed in a prospective incident monitoring study at two hospitals. Anaesthetists completed an incident form for every anaesthetic, indicating if an incident occurred. Case mix data were collected and the number of drug administrations made during procedures estimated. From February 1998 at Hospital A and from June 1999 at Hospital B, until November 2003, 74,478 anaesthetics were included, for which 59,273 incident forms were returned (a 79.6% response rate). Fewer parenteral drug errors occurred with the new system than with conventional methods (58 errors in an estimated 183,852 drug administrations (0.032%, 95% CI 0.024-0.041%) vs 268 in 550,105 (0.049%, 95% CI 0.043-0.055%) respectively, p = 0.002), a relative reduction of 35% (difference 0.017%, 95% CI 0.006-0.028%). No major adverse outcomes from these errors were reported with the new system while 11 (0.002%) were reported with conventional methods (p = 0.055). We conclude that targeted system re-design can reduce medical error.
在两家医院进行的前瞻性事件监测研究中，评估了一种以安全为导向的静脉麻醉药物给药系统。麻醉师为每例麻醉完成一份事件报告表，指明是否发生了事件。收集病例组合数据，并估计在手术过程中进行的药物给药次数。从 1998 年 2 月在医院 A 开始，从 1999 年 6 月在医院 B 开始，直到 2003 年 11 月，共纳入 74478 例麻醉，其中 59273 份事件报告表（应答率 79.6%）返回。新系统比传统方法发生的静脉药物错误更少（新系统在估计的 183852 次药物给药中发生 58 次错误（0.032%，95%CI 0.024-0.041%），而传统方法在 550105 次（0.049%，95%CI 0.043-0.055%）中发生 268 次，差异有统计学意义（p = 0.002），相对减少 35%（差值 0.017%，95%CI 0.006-0.028%）。新系统没有报告这些错误导致的重大不良后果，而传统方法报告了 11 例（0.002%）（p = 0.055）。我们得出结论，有针对性的系统重新设计可以减少医疗差错。
