Vialle V, Tiphine T, Poirier Y, Raingeard E, Feldman D, Freville J-C
Service de pharmacie, centre hospitalier départemental de La-Roche-sur-Yon, France.
Ann Pharm Fr. 2011 May;69(3):165-76. doi: 10.1016/j.pharma.2011.01.005. Epub 2011 Mar 3.
The aim of the study is to identify medication errors related to computerized physician order entry in our hospital.
At the end of this 1-year study (2008 to 2009), 378 beds were computerized by a business software. Medication errors were identified from notifications sent to the publisher of the software, feedback of health professionals and the analysis of Pharmacists' interventions formulate following prescription errors due to computerization. They were qualified according to the medication error's French dictionary of the French Society of Clinical Pharmacy.
Thirty-five categories of medication errors were found. Most of them appear during prescription. Dosage and concentration errors, dose errors, omission errors and drug errors are the most frequent.
DISCUSSION-CONCLUSION: Three main causes were found: human factor, closely related to the software settings and the quality of user training; communication problems, related to the ergonomics; conception problems, related to intuitiveness and intricacy of the software. These results confirm the existence of medication errors induced by computerized physician order entry systems. They highlight the need to involve initial and ongoing training of users, relevance and scalability of the setup and use of mature and certified software to minimized them.
本研究旨在识别我院与计算机化医师医嘱录入相关的用药错误。
在这项为期1年的研究（2008年至2009年）结束时，378张床位通过商业软件实现了计算机化。用药错误通过发送给软件发布商的通知、卫生专业人员的反馈以及对因计算机化导致的处方错误后药剂师干预措施的分析来识别。根据法国临床药学协会的用药错误法语词典对其进行分类。
发现了35类用药错误。其中大多数出现在处方开具过程中。剂量和浓度错误、剂量差错、遗漏错误和药物错误最为常见。
讨论 - 结论：发现了三个主要原因：人为因素，与软件设置和用户培训质量密切相关；沟通问题，与人体工程学有关；概念问题，与软件的直观性和复杂性有关。这些结果证实了计算机化医师医嘱录入系统会导致用药错误的存在。它们强调需要对用户进行初始和持续培训，设置的相关性和可扩展性以及使用成熟且经过认证的软件以将其最小化。
