McKaig Donald, Collins Christine, Elsaid Khaled A
Jt Comm J Qual Patient Saf. 2014 Sep;40(9):398-407. doi: 10.1016/s1553-7250(14)40052-7.
A study was conducted to evaluate the impact of a reengineered approach to electronic error reporting at a 719-bed multidisciplinary urban medical center.
The main outcome of interest was the monthly reported medication errors during the preimplementation (20 months) and postimplementation (26 months) phases. An interrupted time series analysis was used to describe baseline errors, immediate change following implementation of the current electronic error-reporting system (e-ERS), and trend of error reporting during postimplementation. Errors were categorized according to severity using the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Medication Error Index classifications. Reported errors were further analyzed by reporter and error site.
During preimplementation, the monthly reported errors mean was 40.0 (95% confidence interval [CI]: 36.3-43.7). Immediately following e-ERS implementation, monthly reported errors significantly increased by 19.4 errors (95% CI: 8.4-30.5). The change in slope of reported errors trend was estimated at 0.76 (95% CI: 0.07-1.22). Near misses and no-patient-harm errors accounted for 90% of all errors, while errors that caused increased patient monitoring or temporary harm accounted for 9% and 1%, respectively. Nurses were the most frequent reporters, while physicians were more likely to report high-severity errors. Medical care units accounted for approximately half of all reported errors.
Following the intervention, there was a significant increase in reporting of prevented errors and errors that reached the patient with no resultant harm. This improvement in reporting was sustained for 26 months and has contributed to designing and implementing quality improvement initiatives to enhance the safety of the medication use process.
开展了一项研究，以评估在一家拥有719张床位的多学科城市医疗中心重新设计电子错误报告方法的影响。
主要关注的结果是实施前阶段（20个月）和实施后阶段（26个月）每月报告的用药错误。采用中断时间序列分析来描述基线错误、当前电子错误报告系统（e-ERS）实施后的即时变化以及实施后错误报告的趋势。使用国家用药错误报告和预防协调委员会（NCC MERP）用药错误指数分类法根据严重程度对错误进行分类。报告的错误进一步按报告者和错误发生地点进行分析。
在实施前阶段，每月报告的错误平均数为40.0（95%置信区间[CI]：36.3 - 43.7）。在e-ERS实施后，每月报告的错误显著增加了19.4起（95% CI：8.4 - 30.5）。报告错误趋势的斜率变化估计为0.76（95% CI：0.07 - 1.22）。险些发生的错误和未对患者造成伤害的错误占所有错误的90%，而导致增加患者监测或暂时伤害的错误分别占9%和1%。护士是最频繁的报告者，而医生更有可能报告高严重程度的错误。医疗护理单元占所有报告错误的近一半。
干预后，预防错误以及虽已发生但未对患者造成伤害的错误的报告显著增加。这种报告方面的改善持续了26个月，并有助于设计和实施质量改进举措，以提高用药过程的安全性。
