Grissinger Matthew C, Hicks Rodney W, Keroack Mark A, Marella William M, Vaida Allen J
Pennsylvania Patient Safety Reporting System, Institute for Safe Medication Practices, Horsham, Pennsylvania, USA.
Jt Comm J Qual Patient Saf. 2010 May;36(5):195-202. doi: 10.1016/s1553-7250(10)36032-6.
External reporting of medical errors a adverse events enables learning from the errors of others in the pursuit of systems-level improvements that can prevent future errors. It is logical to presume that medication errors involving the use of anticoagulants, among the most frequently cited product classes involved in harmful medication errors, would be captured in a variety of patient safety reporting programs.
Data on reported errors involving the anticoagulant heparin were reviewed, compared, and aggregated from the databases of three large patient safety reporting programs-MEDMARX, the Pennsylvania Patient Safety Authority's Patient Safety Reporting System, and the University Health System Consortium, together representing more than 1,000 reporting organizations for 2005
Approximately 300,000 medication errors and near misses were reported to the programs, and 10,359-a mean of 3.6% (range, 3.1%-5.5%)-involved heparin products. The proportion of heparin-related reports that involved patient harm ranged from 1.4% to 4.9%. The phase of the medication use process cited most frequently in harmful events was the administration phase (56% of errors leading to harm), followed by the prescribing phase (19% of errors leading to harm).
This study represents the first attempt by these three large reporting systems to combine data on a single clinical process. The consistent patterns evident in the reports, such as the percentage of all medication errors that involved heparin, suggests that reporting programs, at least for common events such as medication errors, may reach a point of diminishing returns in which aggregating more reports of a certain type yields no additional insight once a large volume of similar events is captured and analyzed.
医疗差错和不良事件的外部报告有助于从他人的差错中吸取教训，以寻求系统层面的改进，从而预防未来的差错。可以合理推测，在有害用药差错中最常被提及的产品类别中，涉及抗凝剂使用的用药差错会在各种患者安全报告项目中被记录下来。
对三个大型患者安全报告项目（MEDMARX、宾夕法尼亚州患者安全管理局的患者安全报告系统以及大学卫生系统联盟）数据库中报告的涉及抗凝剂肝素的差错数据进行了审查、比较和汇总，这三个项目总共代表了2005年的1000多个报告机构。
这些项目共收到约30万例用药差错和险些发生的差错报告，其中10359例（平均占3.6%，范围为3.1%-5.5%）涉及肝素产品。涉及患者伤害的肝素相关报告比例在1.4%至4.9%之间。有害事件中最常被提及的用药过程阶段是给药阶段（导致伤害的差错中有56%），其次是处方阶段（导致伤害的差错中有19%）。
本研究是这三个大型报告系统首次尝试整合关于单个临床过程的数据。报告中明显的一致模式，如所有用药差错中涉及肝素的百分比，表明报告项目，至少对于用药差错等常见事件而言，可能会达到收益递减的点，即一旦大量类似事件被收集和分析，汇总更多某类报告不会带来更多见解。
