van de Plas Afke, Slikkerveer Mariëlle, Hoen Saskia, Schrijnemakers Rick, Driessen Johanna, de Vries Frank, van den Bemt Patricia
Maastricht UMC+, the Netherlands.
BMJ Qual Improv Rep. 2017 Jun 15;6(1). doi: 10.1136/bmjquality.u215011.w5936. eCollection 2017.
In this controlled before-after study the effect of improvements, derived from Lean Six Sigma strategy, on parenteral medication administration errors and the potential risk of harm was determined. During baseline measurement, on control versus intervention ward, at least one administration error occurred in 14 (74%) and 6 (46%) administrations with potential risk of harm in 6 (32%) and 1 (8%) administrations. Most administration errors with high potential risk of harm occurred in bolus injections: 8 (57%) versus 2 (67%) bolus injections were injected too fast with a potential risk of harm in 6 (43%) and 1 (33%) bolus injections on control and intervention ward. Implemented improvement strategies, based on major causes of too fast administration of bolus injections, were: Substitution of bolus injections by infusions, education, availability of administration information and drug round tabards. Post intervention, on the control ward in 76 (76%) administrations at least one error was made (RR 1.03; CI95:0.77-1.38), with a potential risk of harm in 14 (14%) administrations (RR 0.45; CI95:0.20-1.02). In 40 (68%) administrations on the intervention ward at least one error occurred (RR 1.47; CI95:0.80-2.71) but no administrations were associated with a potential risk of harm. A shift in wrong duration administration errors from bolus injections to infusions, with a reduction of potential risk of harm, seems to have occurred on the intervention ward. Although data are insufficient to prove an effect, Lean Six Sigma was experienced as a suitable strategy to select tailored improvements. Further studies are required to prove the effect of the strategy on parenteral medication administration errors.
在这项前后对照的对照研究中，确定了源自精益六西格玛策略的改进措施对肠外用药给药错误及潜在伤害风险的影响。在基线测量期间，在对照病房和干预病房，分别有14次（74%）和6次（46%）给药至少发生了1次给药错误，有潜在伤害风险的给药分别为6次（32%）和1次（8%）。大多数具有高潜在伤害风险的给药错误发生在大剂量注射中：对照病房和干预病房分别有8次（57%）和2次（67%）大剂量注射注射速度过快，有潜在伤害风险的大剂量注射分别为6次（43%）和1次（33%）。基于大剂量注射给药速度过快的主要原因实施的改进策略包括：用输液替代大剂量注射、教育培训、提供给药信息以及使用药物巡视识别卡。干预后，对照病房在76次（76%）给药中至少出现了1次错误（相对危险度1.03；95%置信区间：0.77 - 1.38），有潜在伤害风险的给药为14次（14%）（相对危险度0.45；95%置信区间：0.20 - 1.02）。干预病房在40次（68%）给药中至少出现了1次错误（相对危险度1.47；95%置信区间：0.80 - 2.71），但没有给药与潜在伤害风险相关。在干预病房似乎出现了错误给药持续时间从大剂量注射向输液的转变，且潜在伤害风险降低。尽管数据不足以证明有效果，但精益六西格玛被认为是选择针对性改进措施的合适策略。需要进一步研究来证明该策略对肠外用药给药错误的影响。
