Department of Emergency Medicine and Department of Anesthesiology, Division of Critical Care, University of California, San Diego, San Diego, CA, United States.
Department of Anesthesiology, Division of Critical Care, University of California, San Diego, San Diego, CA, United States.
J Crit Care. 2018 Feb;43:366-369. doi: 10.1016/j.jcrc.2017.09.018. Epub 2017 Sep 12.
Medical errors play a large role in preventable harms within our health care system. Medications administered in the ICU can be numerous, complex and subject to daily changes. We describe a method to identify medication errors with the potential to improve patient safety.
A quality improvement intervention featuring a daily medication time out for each patient was performed during rounds.
A 12-bed Cardiac Surgical ICU at a single academic institution with approximately 180 beds.
After each patient encounter, the current medication list for the patient was read aloud from the electronic medical record, and the team would determine if any were erroneous or missing. Medication changes were recorded and graded post-hoc according to perceived significance.
This intervention resulted in 285 medication changes in 347 patient encounters. 179 of the 347 encounters (51.6%) resulted in at least one change. Of the changes observed, 40.4% were categorized as trivial, 50.5% as minor and 9.1% were considered to have significant potential impact on patient care. The average time spent per patient for this intervention was 1.24 (SD 0.65) minutes.
A daily medication time out should be considered as an additional mechanism for patient safety in the ICU.
在我们的医疗保健系统中，医疗失误在可预防的伤害中起了很大的作用。重症监护病房（ICU）中使用的药物可能数量众多、复杂且每天都有变化。我们描述了一种识别潜在提高患者安全性的药物错误的方法。
在查房时，对每位患者进行日常药物暂停的质量改进干预。
一家拥有约 180 张床位的 12 张心脏外科 ICU 的单一学术机构。
在每次患者就诊后，从电子病历中大声朗读当前患者的用药清单，团队将确定是否存在任何错误或遗漏的药物。药物变化将根据感知的重要性进行记录和事后分级。
该干预措施导致 347 次患者就诊中的 285 次药物变化。347 次就诊中有 179 次（51.6%）至少有一次变化。观察到的变化中，40.4%被归类为微不足道，50.5%为轻微，9.1%被认为对患者护理有重大潜在影响。每次干预的每位患者平均用时为 1.24 分钟（标准差为 0.65）。
在 ICU 中，应考虑每日药物暂停作为患者安全的附加机制。
