Meyer-Massetti C, Conen D
Stiftung für Patientensicherheit, Schweiz, Zurich.
Ther Umsch. 2012 Jun;69(6):347-52. doi: 10.1024/0040-5930/a000296.
Medication errors are responsible for up to 50% of errors in healthcare. Therefore, they are an important target for the improvement of patient safety. The application of evidence-based methods for the analysis of institution-specific medication safety hotspots is crucial. Recommended methods for the identification of medication safety problems have individual strengths and weaknesses, but there is little overlap. Consequently, a combination of methods is recommended. While the analysis of critical incident reporting systems preferentially identifies serious medication errors, trigger tool represents an effective and cost-efficient approach. Evidence-based data for improvement methods is limited. However, the implementation of clinical pharmacy services, IT tools (electronic prescribing, barcoding) and standardized double-check showed a significant impact on error reduction. In addition, the support of institutional leadership is an important prerequisite.
用药错误占医疗保健错误的比例高达50%。因此，它们是改善患者安全的重要目标。应用循证方法分析特定机构的用药安全热点至关重要。推荐的用于识别用药安全问题的方法各有优缺点，但重叠之处很少。因此，建议采用多种方法相结合。虽然对关键事件报告系统的分析优先识别严重用药错误，但触发工具是一种有效且具有成本效益的方法。用于改进方法的循证数据有限。然而，临床药学服务、信息技术工具（电子处方、条形码）的实施以及标准化双人核对对减少错误有显著影响。此外，机构领导的支持是一个重要前提。
