Duthie Elizabeth, Favreau Barbara, Ruperto Angelo, Mannion Janet, Flink Ellen, Leslie Ruth
New York State Department of Health, Delmar, NY (AR, EF). New York State Department of Health, Troy, NY (JM, RL). New York University Hospital, New York, NY (ED). Crouse Hospital, Syracuse, NY (BF)
In June 2000, the New York State Department of Health (NYSDOH) expanded its New York Patient Occurrence Reporting and Tracking System (NYPORTS) mandatory adverse event reporting system to include the reporting of medication errors. The errors included were those that resulted in a severity of patient harm that met the National Coordinating Council Medication Error Reporting Program (NCC MERP) criteria for categories G (resulting in permanent patient harm), H (resulting in a near-death event) and I (resulting in patient death). Root cause analyses (RCA) that examine systems issues and identify mechanisms for future prevention of these events were studied. A panel of 11 multidisciplinary professionals performed a quantitative and qualitative analysis of 24 months of medication errors reports submitted to the NYPORTS system. NYPORTS requires that the 249 hospitals in New York State (NYS) electronically notify the NYSDOH of reportable errors within 24 hours of occurrence detection and that a RCA for that occurrence be submitted within 30 days. Qualitative analysis of the RCAs included findings related to lessons learned, emergent themes, and use of system fixes instead of punitive fixes or inappropriate/incomplete system fixes. The quantitative analysis examined several variables. These included where in the process the error occurred, what disciplines were involved, the error distribution, the occurrence type, the medication or medication classes involved, and the breakdown by patient outcome. Mandatory medication error reporting can provide useful information about systems contributing to errors, strategies for prevention, and evidence-based information about patient safety concepts. This information is important for hospitals to consider both when analyzing medication errors and when implementing systems to improve safety. This report is intended to help guide public policy and provide guidance to other states interested in establishing mandatory reporting systems.
2000年6月，纽约州卫生部（NYSDOH）扩大了其纽约患者事件报告与追踪系统（NYPORTS）的强制性不良事件报告系统，将用药错误报告纳入其中。所纳入的错误是那些导致患者伤害严重程度符合国家协调委员会用药错误报告计划（NCC MERP）中G类（导致患者永久性伤害）、H类（导致濒死事件）和I类（导致患者死亡）标准的错误。对审查系统问题并确定未来预防这些事件机制的根本原因分析（RCA）进行了研究。一个由11名多学科专业人员组成的小组对提交给NYPORTS系统的24个月用药错误报告进行了定量和定性分析。NYPORTS要求纽约州（NYS）的249家医院在检测到可报告错误后的24小时内以电子方式通知NYSDOH，并在30天内提交该事件的RCA。对RCA的定性分析包括与经验教训、新出现的主题以及使用系统修复而非惩罚性修复或不适当/不完整系统修复相关的发现。定量分析考察了几个变量。这些变量包括错误发生在流程中的哪个环节、涉及哪些学科、错误分布、事件类型、涉及的药物或药物类别以及按患者结果的分类。强制性用药错误报告可以提供有关导致错误的系统、预防策略以及患者安全概念的循证信息的有用信息。这些信息对于医院在分析用药错误以及实施提高安全性的系统时都很重要。本报告旨在帮助指导公共政策，并为其他有兴趣建立强制性报告系统的州提供指导。
