Binzer Kristine, Hellebek Annemarie
Unit for Patient Safety, Capital Region of Denmark.
Stud Health Technol Inform. 2011;166:31-7.
We have previously studied system failures involved in medication errors using a limited number of root cause analyses as source. The aim of this study was to describe a larger number of medication errors with respect to harm, involved medicines and involved system problems - thus providing information for the development of IT-based decision support. We evaluated 3,520 medication error reports derived from 12 months of consecutive reporting from 13 hospitals in the Capital Region of Denmark. We found 0.65% errors with serious harm and 16% with moderate harm. A small number of medicines were involved in the majority of the errors. The problems in the medication error process were heterogeneous. Some were related to specific medicines and others were related to the computerized order entry system. Accordingly decision support targeted at specific medicines and improved IT systems are part of the continuing work to reduce the frequency of medication errors.
我们之前以有限数量的根本原因分析为来源，研究了与用药错误相关的系统故障。本研究的目的是描述大量关于伤害、所涉药品和所涉系统问题的用药错误，从而为基于信息技术的决策支持的开发提供信息。我们评估了来自丹麦首都地区13家医院连续12个月报告的3520份用药错误报告。我们发现0.65%的错误造成严重伤害，16%造成中度伤害。大多数错误涉及少数几种药品。用药错误过程中的问题是多种多样的。一些与特定药品有关，另一些与计算机化医嘱录入系统有关。因此，针对特定药品的决策支持和改进的信息技术系统是持续减少用药错误频率工作的一部分。
