Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN 37212, USA.
Am J Health Syst Pharm. 2011 Mar 1;68(5):434-41. doi: 10.2146/ajhp090666.
Medication-error alerts for warfarin orders detected by a bar-code-assisted medication administration (BCMA) system were evaluated.
All patients receiving warfarin who were admitted to a university medical center between July 1, 2008, and February 6, 2009, in inpatient units with BCMA systems were candidates for inclusion in this study. Medication-error alerts displayed to the nurse administering the warfarin were reviewed to determine whether a true potential error was detected. Each alert was converted to a scenario, and its potential to require treatment or cause patient harm was rated using a validated severity scale of 0-10, where a score of 0 indicated no probable effect on the patient and 10 indicated that the error would likely result in patient death. A severity score was obtained by averaging the scores of four pharmacist reviewers.
Of the 18,393 warfarin doses ordered during the study period for 2,404 patients, error alerts associated with only 99 warfarin doses were found to be clinically meaningful. The mean ± S.D. severity rating of these alerts was low (2.93 ± 1.42), with a standardized Cronbach's coefficient alpha of 0.845. The mean ± S.D. warfarin dose attempted when the nurse received an alert was 4.10 ± 2.48 mg. The majority of doses with alerts (70%) were for patients who had an active order for warfarin.
Of the large number of medication-error alerts generated through a BCMA system, only a small proportion were considered clinically significant. This indicated that the rate of false-positive alerts was unexpectedly high, increasing the risk of alert fatigue.
评估通过条码辅助给药（BCMA）系统检测到的华法林医嘱的用药错误警报。
所有于 2008 年 7 月 1 日至 2009 年 2 月 6 日期间在具有 BCMA 系统的住院病房中接受华法林治疗的住院患者均符合纳入本研究的标准。审查了给药护士显示的用药错误警报，以确定是否检测到真正的潜在错误。将每个警报转换为一个场景，并使用经过验证的 0-10 严重程度评分来评估其潜在的治疗需求或对患者造成的危害，其中 0 分表示对患者无可能影响，10 分表示该错误可能导致患者死亡。严重程度评分通过四名药剂师评审员的评分平均值获得。
在所研究的 2404 名患者的 18393 次华法林剂量中，仅发现与 99 次华法林剂量相关的错误警报具有临床意义。这些警报的平均严重程度评分为 2.93 ± 1.42，标准化 Cronbach's 系数 alpha 为 0.845。护士收到警报时尝试的平均华法林剂量为 4.10 ± 2.48mg。大多数带有警报的剂量（70%）是为有华法林活性医嘱的患者开出的。
在 BCMA 系统生成的大量用药错误警报中，只有一小部分被认为具有临床意义。这表明假阳性警报的比率出乎意料地高，增加了警报疲劳的风险。
