Neville R G, Robertson F, Livingstone S, Crombie I K
J R Coll Gen Pract. 1989 Mar;39(320):110-2.
Three independent methods of study of prescription errors led to the development of a classification of errors based on the potential effects and inconvenience to patients, pharmacists and doctors. Four types of error are described: type A (potentially serious to patient); type B (major nuisance - pharmacist/doctor contact required); type C (minor nuisance - pharmacist must use professional judgement); and type D (trivial). The types of frequency of errors are detailed for a group of eight principals from one health centre. There were a total of 504 errors from 15,916 prescription items (3.17%) during a three month observation period. A close correspondence was found between individual doctor's types of error rates, suggesting that doctors who make type C and D errors are also likely to make type B (major nuisance) errors. A system of feedback of errors from each doctor was devised. No significant reduction was seen in error rates, possibly because the group of self selected doctors taking part had low error rates initially. It is suggested that pharmacists and doctors should work closely together to prevent the potentially harmful consequences of prescription errors.
三种独立的处方错误研究方法促成了一种基于对患者、药剂师和医生的潜在影响及不便程度的错误分类。文中描述了四种错误类型：A类（对患者有潜在严重影响）；B类（较大麻烦——需要药剂师/医生介入）；C类（较小麻烦——药剂师必须运用专业判断）；D类（微不足道）。文中详细列出了来自一个健康中心的八位负责人的错误发生频率类型。在三个月的观察期内，15916份处方中共有504处错误（3.17%）。研究发现个别医生的错误率类型之间存在密切对应关系，这表明犯C类和D类错误的医生也很可能犯B类（较大麻烦）错误。设计了一个针对每位医生的错误反馈系统。错误率未见显著降低，可能是因为参与研究的这批自行选择的医生最初的错误率就较低。建议药剂师和医生应密切合作，以防止处方错误带来潜在有害后果。
