Allan E L, Barker K N
Department of Pharmacy Care Systems, School of Pharmacy, Auburn University, AL 36849-5506.
Am J Hosp Pharm. 1990 Mar;47(3):555-71.
Types of medication errors are defined, error detection techniques are described, and the validity of several medication error studies is evaluated. A medication error is generally defined as a deviation from the physician's medication order as written on the patient's chart. In hospitals, medication errors occur at a rate of about one per patient per day. A dispensing error is one made by pharmacy staff when distributing medications to nursing units or directly to patients in an ambulatory-care pharmacy; the error rates for doses dispensed via the cart-filling process range from 0.87% to 2.9%. Categories of medication errors should be operationally defined before an investigation, and any allowable deviations from the physician's order should be clearly stated. Fourteen error category definitions are presented. Methods for detecting medication errors include anonymous self-reports (questionnaires), incident reports, the critical-incident technique (analyses of a large number of individual errors to identify common causal factors), and direct observation (including the disguised-observation and participant observer techniques). Observation is the best error detection method in terms of accuracy. Results of medication error studies were examined for validity and classified into one of four categories: (A) results should be accepted as reported, (B) results overestimate or underestimate the truth by a known amount, (C) results overestimate the truth by an unknown amount, and (D) results should not be accepted. All studies examined for validity used observation as the error detection technique. The following guidelines for observation-based medication error studies were established: The observer should follow the subject to the patient's bedside, the observer should witness patient consumption of each dose, the observer should not be familiar with patient drug regimens before observation, operational definitions must be used, and having an error validation committee can be advantageous. Future studies are needed that focus on the identification and testing of new error prevention methods that use the techniques described.
定义了用药错误的类型，描述了错误检测技术，并评估了几项用药错误研究的有效性。用药错误通常定义为与医生在患者病历上所写的用药医嘱存在偏差。在医院里，用药错误的发生率约为每位患者每天1次。调配错误是指药房工作人员在向护理单元分发药品或在门诊药房直接向患者发药时所犯的错误；通过推车配药过程分发的剂量错误率在0.87%至2.9%之间。在进行调查之前，应从操作层面定义用药错误的类别，并应明确说明与医生医嘱的任何允许偏差。给出了14种错误类别定义。检测用药错误的方法包括匿名自我报告（问卷调查）、事件报告、关键事件技术（对大量个体错误进行分析以确定共同的因果因素）和直接观察（包括伪装观察和参与观察者技术）。就准确性而言，观察是最佳的错误检测方法。对用药错误研究的结果进行了有效性检查，并分为四类之一：（A）结果应按报告接受，（B）结果高估或低估实际情况的幅度已知，（C）结果高估实际情况的幅度未知，以及（D）结果不应被接受。所有接受有效性检查的研究都使用观察作为错误检测技术。制定了以下基于观察的用药错误研究指南：观察者应跟随受试者到患者床边，观察者应目睹患者服用每剂药物，观察者在观察前不应熟悉患者的用药方案，必须使用操作定义，并且设立一个错误验证委员会可能会有帮助。需要开展未来研究，重点是识别和测试使用所述技术的新的错误预防方法。
