Epworth Deakin Centre for Clinical Nursing Research, Richmond, Vic, Australia.
J Clin Nurs. 2013 Feb;22(3-4):579-89. doi: 10.1111/j.1365-2702.2012.04326.x. Epub 2012 Sep 24.
To explore the effects of introducing an electronic medication management system on reported medication errors.
Computerised medication management systems have been found to improve medication safety; however, introducing medication management system into healthcare environments can create unanticipated or new problems and opportunities for medication error.
Descriptive analysis of medication error reports.
This was a retrospective analysis of 359 incident reports drawn from the period of 1 May 2005-30 April 2006 across two hospital sites of a single not-for-profit private health service located in metropolitan Melbourne. Site A used a conventional pen and paper system for medication management, and Site B had introduced a computerised medication management system.
Most medication errors occurred at the nurse administration (71·5%) and prescribing (16·4%) stages of delivery. The most common medication error type reported at Site A was omission (33%), and at Site B was wrong documentation (24·2%). A higher proportion of errors at the prescribing phase, and less nurse administration errors, were detected at Site B where the medication management system was in use. The incidence of other, less frequent errors was similar across the two hospital sites.
This examination of medication error reports suggests there are differences in the types of medication errors that are reported in association with the introduction of electronic medication management system compared to pen and paper system systems. The findings provide a new insight into the effects of introducing an electronic medication management system on the types of medication errors reported.
The findings provide a new insight into the types of medication errors that are reported during implementation of an electronic medication management system. Extra support for physicians prescribing practices should be considered.
探讨引入电子药物管理系统对报告药物错误的影响。
已发现计算机化药物管理系统可提高药物安全性；然而，在医疗保健环境中引入药物管理系统可能会为药物错误带来意想不到或新的问题和机会。
对药物错误报告的描述性分析。
这是对 2005 年 5 月 1 日至 2006 年 4 月 30 日期间来自墨尔本大都会区一家非营利性私人医疗服务的两个医院站点的 359 份事件报告的回顾性分析。站点 A 使用常规的纸笔系统进行药物管理，而站点 B 则引入了计算机化药物管理系统。
大多数药物错误发生在给药的护士给药（71.5%）和开处方（16.4%）阶段。在站点 A 报告的最常见药物错误类型是遗漏（33%），在站点 B 是错误记录（24.2%）。在使用药物管理系统的站点 B 中，发现开处方阶段的错误比例更高，而护士给药错误则更少。两个医院站点的其他较少见的错误发生率相似。
对药物错误报告的检查表明，与引入电子药物管理系统相比，在引入电子药物管理系统时报告的药物错误类型存在差异。调查结果为了解引入电子药物管理系统对报告的药物错误类型的影响提供了新的见解。
调查结果为实施电子药物管理系统期间报告的药物错误类型提供了新的见解。应该考虑为医生的开处方实践提供额外的支持。
