García-Ramos S E, Baldominos Utrilla G
Servicio de Farmacia, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, España.
Farm Hosp. 2011 Mar-Apr;35(2):64-9. doi: 10.1016/j.farma.2010.06.002. Epub 2010 Nov 18.
To assess the impact of administration errors when transcribing treatments to nurses' administration forms, and to estimate the impact of electronically assisted prescription (EAP) in minimising these errors.
A prospective, observational study in hospitalised patients. In a representative sample changes in treatment in the 24 h before the examination are analysed. Transcription errors were detected when checking the discrepancies between the medical prescription and the nurses' treatment administration forms. Error incidence was calculated as a whole and by ward, type of error, administration route and their potential danger. The possible reduction in new errors per day if the EAP were to be introduced in all units was estimated.
Of the 416 prescriptions recorded, the overall percentage of transcription errors was 12.4%, 9.8% in medical units and 15.2% in surgical units. Most of the errors were made when a new medicine was added (29.4%) and the frequency of administration was changed (27.4%). With regard to their gravity, 98% did not harm the patients, and 57.7% were filed as "Category C". Taking into account that 1 change of treatment is made per patient per day, the introduction of the EAP is predicted to prevent 64 new errors daily in the hospital.
There are so many transcription errors that they should be taken into account when designing strategies to improve care quality. EAP is an efficient tool to eliminate errors associated with the transcription of prescriptions.
评估将治疗信息转录到护士执行表单时给药错误的影响,并估计电子辅助处方(EAP)在减少这些错误方面的影响。
对住院患者进行一项前瞻性观察研究。分析检查前24小时内治疗的代表性样本变化。通过核对医疗处方与护士治疗执行表单之间的差异来检测转录错误。计算总体及按病房、错误类型、给药途径及其潜在危险性的错误发生率。估计若在所有科室引入EAP,每天新错误可能减少的数量。
在记录的416份处方中,转录错误的总体百分比为12.4%,内科科室为9.8%,外科科室为15.2%。大多数错误发生在添加新药(29.4%)和改变给药频率(27.4%)时。就其严重性而言,98%未对患者造成伤害,57.7%被列为“C类”。考虑到每位患者每天有1次治疗变更,预计引入EAP可使医院每天预防64例新错误。
存在如此多的转录错误,在设计提高护理质量的策略时应予以考虑。EAP是消除与处方转录相关错误的有效工具。