Richardson Barbara, Bromirski Bridget, Hayden Avis
Southwestern Vermont Medical Center, Bennington, VT, USA.
Clin Nurse Spec. 2012 May-Jun;26(3):169-76. doi: 10.1097/NUR.0b013e3182503fbe.
PURPOSE/OBJECTIVES: The goal of this article was to outline a process change in medication administration using technology and led by clinical nurse specialists (CNSs) that has been successful and sustainable over time.
BACKGROUND/RATIONALE: The Institute of Medicine published a landmark report in September 1999 estimating that between 44 000 and 98 000 patients die each year because of medical errors. Errors are rarely the result of incompetent individuals using intentionally unsafe practices. Instead, errors usually result from poorly designed systems that do not prevent errors from occurring. Medication administration is an example of a multistep system that, because of its complexity, can be a challenge to accomplish safely and without error. It is estimated that errors from medication administration have led to 7000 deaths per year.
DESCRIPTION OF THE PROJECT/INNOVATION: Using an electronic medication administration record with bar-code scanning for both patient and medication verification at the bedside is a technological methodology known to enhance medication administration safety. Many organizations have adopted these technologies, but not all have shown exceptional and sustained successes leading to a safer hospital experience for their patients. This article outlines the key steps that guided the CNSs from a small Magnet-designated New England hospital to improve medication administration safety. The project improvements were framed in the methods of reliability science.
The article describes a practice change for nurses and pharmacists that resulted in sustained bedside medication scan rates of greater than 97% and medication error reduction from 2.89 errors per 10 000 doses before implementation of electronic medication administration record to a current rate of 1.48 errors per 10 000 doses.
INTERPRETATION/CONCLUSION: This improvement project demonstrates that CNSs can play a vital role in bringing electronic medication administration to the hospital environment. The CNS leaders established a network of relationships with experts in pharmacy, information technology, and patient safety to address the varied stakeholder interests.
目的/目标：本文的目的是概述在临床护理专家（CNS）主导下，利用技术进行药物管理的流程变革，该变革长期以来一直成功且可持续。
背景/基本原理：医学研究所于1999年9月发表了一份具有里程碑意义的报告，估计每年有44000至98000名患者因医疗差错死亡。差错很少是由于不称职的个人故意采用不安全做法导致的。相反，差错通常是由于设计不佳的系统未能防止差错发生所致。药物管理是一个多步骤系统的例子，由于其复杂性，安全无误地完成具有挑战性。据估计，药物管理差错每年导致7000人死亡。
项目/创新描述：使用带有条形码扫描的电子药物管理记录，在床边对患者和药物进行核查，这是一种已知可提高药物管理安全性的技术方法。许多机构都采用了这些技术，但并非所有机构都取得了显著且持续的成功，为患者带来更安全的医院体验。本文概述了一家新英格兰小型磁体认证医院的临床护理专家为提高药物管理安全性所采取的关键步骤。项目改进采用了可靠性科学方法。
本文描述了一项针对护士和药剂师的实践变革，其结果是床边药物扫描率持续高于97%，药物差错率从实施电子药物管理记录前的每10000剂2.89次差错降至目前的每10000剂1.48次差错。
解读/结论：该改进项目表明，临床护理专家在将电子药物管理引入医院环境方面可发挥至关重要的作用。临床护理专家领导者与药学、信息技术和患者安全方面的专家建立了关系网络，以满足不同利益相关者的利益需求。
