Huckels-Baumgart Saskia, Baumgart André, Buschmann Ute, Schüpfer Guido, Manser Tanja
Department Wolhusen.
Department of Anesthesiology, Cantonal Hospital Lucerne, Lucerne, Switzerland.
J Patient Saf. 2021 Apr 1;17(3):e161-e168. doi: 10.1097/PTS.0000000000000335.
Interruptions and errors during the medication process are common, but published literature shows no evidence supporting whether separate medication rooms are an effective single intervention in reducing interruptions and errors during medication preparation in hospitals. We tested the hypothesis that the rate of interruptions and reported medication errors would decrease as a result of the introduction of separate medication rooms.
Our aim was to evaluate the effect of separate medication rooms on interruptions during medication preparation and on self-reported medication error rates.
We performed a preintervention and postintervention study using direct structured observation of nurses during medication preparation and daily structured medication error self-reporting of nurses by questionnaires in 2 wards at a major teaching hospital in Switzerland.
A volunteer sample of 42 nurses was observed preparing 1498 medications for 366 patients over 17 hours preintervention and postintervention on both wards. During 122 days, nurses completed 694 reporting sheets containing 208 medication errors. After the introduction of the separate medication room, the mean interruption rate decreased significantly from 51.8 to 30 interruptions per hour (P < 0.01), and the interruption-free preparation time increased significantly from 1.4 to 2.5 minutes (P < 0.05). Overall, the mean medication error rate per day was also significantly reduced after implementation of the separate medication room from 1.3 to 0.9 errors per day (P < 0.05).
The present study showed the positive effect of a hospital-based intervention; after the introduction of the separate medication room, the interruption and medication error rates decreased significantly.
用药过程中的干扰和错误很常见,但已发表的文献没有证据支持单独的配药室是否是减少医院配药过程中干扰和错误的有效单一干预措施。我们检验了这样一个假设,即引入单独的配药室会使干扰率和报告的用药错误率降低。
我们的目的是评估单独的配药室对配药过程中干扰以及自我报告的用药错误率的影响。
我们在瑞士一家大型教学医院的两个病房进行了一项干预前和干预后的研究,通过对护士配药过程进行直接结构化观察以及通过问卷对护士进行每日结构化用药错误自我报告。
在干预前和干预后的17个小时内,对42名护士的志愿者样本进行了观察,他们为366名患者准备了1498剂药物。在122天里,护士们完成了694份报告表,其中包含208起用药错误。引入单独的配药室后,平均干扰率从每小时51.8次显著降至30次(P < 0.01),无干扰配药时间从1.4分钟显著增加至2.5分钟(P < 0.05)。总体而言,实施单独的配药室后,每天的平均用药错误率也从每天1.3次显著降至0.9次(P < 0.05)。
本研究显示了一项基于医院的干预措施的积极效果;引入单独的配药室后,干扰率和用药错误率显著降低。