Pharmacy Department, Hospital Universitario Ramón y Cajal, Carretera de Colmenar Viejo km 9,1, Madrid 28041, Spain.
BMJ Qual Saf. 2013 Jan;22(1):42-52. doi: 10.1136/bmjqs-2012-000983. Epub 2012 Sep 13.
To identify actions to reduce medication errors in the process of drug prescription, validation and dispensing, and to evaluate the impact of their implementation.
A Health Care Failure Mode and Effect Analysis (HFMEA) was supported by a before-and-after medication error study to measure the actual impact on error rate after the implementation of corrective actions in the process of drug prescription, validation and dispensing in wards equipped with computerised physician order entry (CPOE) and unit-dose distribution system (788 beds out of 1080) in a Spanish university hospital. The error study was carried out by two observers who reviewed medication orders on a daily basis to register prescription errors by physicians and validation errors by pharmacists. Drugs dispensed in the unit-dose trolleys were reviewed for dispensing errors. Error rates were expressed as the number of errors for each process divided by the total opportunities for error in that process times 100.
A reduction in prescription errors was achieved by providing training for prescribers on CPOE, updating prescription procedures, improving clinical decision support and automating the software connection to the hospital census (relative risk reduction (RRR), 22.0%; 95% CI 12.1% to 31.8%). Validation errors were reduced after optimising time spent in educating pharmacy residents on patient safety, developing standardised validation procedures and improving aspects of the software's database (RRR, 19.4%; 95% CI 2.3% to 36.5%). Two actions reduced dispensing errors: reorganising the process of filling trolleys and drawing up a protocol for drug pharmacy checking before delivery (RRR, 38.5%; 95% CI 14.1% to 62.9%).
HFMEA facilitated the identification of actions aimed at reducing medication errors in a healthcare setting, as the implementation of several of these led to a reduction in errors in the process of drug prescription, validation and dispensing.
确定减少处方、核对和发药流程中用药错误的措施，并评估其实施效果。
采用失效模式与效应分析（HFMEA），结合处方、核对和发药流程用药差错的前后对比研究，评估在配备计算机医嘱录入系统（CPOE）和单剂量摆药系统的病房中实施改进措施后对差错率的实际影响（该医院共有 1080 张床位，其中 788 张床位配备了 CPOE 和单剂量摆药系统）。两名观察员每天查看医嘱，记录医师处方错误和药师核对错误。审核单剂量发药车中的发药错误。错误率用每个流程的错误数除以该流程的总差错机会数再乘以 100 表示。
通过对医师进行 CPOE 培训、更新医嘱流程、改进临床决策支持以及自动化与医院患者清单的软件连接，处方错误减少（相对风险降低率（RRR）为 22.0%，95%可信区间（CI）为 12.1%至 31.8%）。通过优化药师实习的患者安全教育时间、制定标准化核对程序和改进软件数据库的某些方面，核对错误减少（RRR 为 19.4%，95%CI 为 2.3%至 36.5%）。两项措施减少了发药错误：重新设计药车加药流程和制定发药前药房核对的方案（RRR 为 38.5%，95%CI 为 14.1%至 62.9%）。
HFMEA 有助于确定减少医疗保健环境中用药错误的措施，因为这些措施的实施降低了处方、核对和发药流程中的错误率。
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