Pharmacy Department, Ground Floor, Charing Cross Hospital, Fulham Palace Road, London, UK.
Postgrad Med J. 2011 Nov;87(1033):739-45. doi: 10.1136/pgmj.2011.117879. Epub 2011 Jul 14.
To compare the prevalence and causes of prescribing errors in newly written medication orders and how quickly they were rectified, in three NHS organisations.
Errors in newly written inpatient and discharge medication orders were recorded in Spring/Summer 2009 by ward pharmacists on medical admissions and surgical wards, as well as the number of erroneous doses administered (or omitted) before errors were corrected. Logistic regression analysis was used to explore the effects of ward (nested within organisation) and clinical specialty, and whether the pharmacist had checked the patient's medication history during data collection. Causes were explored using semistructured interviews with key informants.
Overall, 1025 prescribing errors were identified in 974 of 6605 medication orders (14.7%, 95% confidence interval (CI) 13.8% to 15.6%). A mean of 0.9 doses were administered (or omitted) before each error was corrected (range 0-11), with differences between specialties and organisations. The error rate on medical admissions wards (16.3%) was significantly higher than that on surgical wards (12.2%), but this was accounted for by the higher proportion of prescribing being on admission, where omission of patients' usual medication was often identified. There were significant differences among wards (and organisations). Contributing factors included lack of feedback on errors, poor documentation and communication of prescribing decisions, and lack of information about patients' medication histories from primary care.
There were variations among wards, organisations and specialties in error rates and how quickly they were rectified. Exploring reasons for differences between organisations may be useful in identifying best practice and potential solutions.
比较 NHS 三个组织中新开医嘱中的用药错误发生率及其纠正速度，以及新开医嘱中的用药错误发生率及其纠正速度，以及新开医嘱中的用药错误发生率及其纠正速度。
2009 年春/夏季，病房药剂师在新入院患者和外科病房记录新开出的住院和出院医嘱中的错误，并记录在错误得到纠正之前给药（或漏给）的错误剂量数。使用逻辑回归分析探讨病房（嵌套在组织内）和临床专科以及药剂师在数据收集期间是否检查患者用药史的影响。使用半结构访谈对关键知情人探索错误原因。
总体而言，在 6605 份医嘱中的 974 份（14.7%，95%置信区间[CI]为 13.8%至 15.6%）中发现了 1025 个处方错误。在每个错误得到纠正之前，平均有 0.9 个剂量被给药（或漏给）（范围 0-11），不同专业和组织之间存在差异。内科病房的错误率（16.3%）明显高于外科病房（12.2%），但这是由于入院时开处方的比例较高，通常会发现漏给患者的常规用药。病房之间（和组织之间）存在显著差异。促成因素包括缺乏对错误的反馈、处方决策的记录和沟通不佳，以及缺乏初级保健患者用药史的信息。
在错误率和纠正速度方面，病房、组织和专业之间存在差异。探讨组织之间差异的原因可能有助于确定最佳实践和潜在解决方案。
