Pfeiffer Yvonne, Zimmermann Chantal, Schwappach David L B
Swiss Patient Safety Foundation, Asylstr, Zurich, Switzerland
Institute of Social and Preventive Medicine (ISPM), University of Bern, Zurich, Switzerland.
BMJ Open. 2020 Sep 17;10(9):e039291. doi: 10.1136/bmjopen-2020-039291.
Double checking is used in oncology to detect medication errors before administering chemotherapy. The objectives of the study were to determine the frequency of detected potential medication errors, i.e., mismatching information, and to better understand the nature of these inconsistencies.
In observing checking procedures, field noteswere taken of all inconsistencies that nurses identified during double checking the order against the prepared chemotherapy.
Oncological wards and ambulatory infusion centres of three Swiss hospitals.
Nurses' double checking was observed.
In a qualitative analysis, (1) a category system for the inconsistencies was developed and (2) independently applied by two researchers.
In 22 (3.2%) of 690 observed double checks, 28 chemotherapy-related inconsistencies were detected. Half of them related to non-matching information between order and drug label, while the other half was identified because the nurses used their own knowledge. 75% of the inconsistencies could be traced back to inappropriate orders, and the inconsistencies led to 33 subsequent or corrective actions.
In double check situations, the plausibility of the medication is often reviewed. Additionally, they serve as a correction for errors and that are made much earlier in the medication process, during order. Both results open up new opportunities for improving the medication process.
在肿瘤学中，双重核对用于在给予化疗前检测用药错误。本研究的目的是确定检测到的潜在用药错误的频率，即信息不匹配，并更好地理解这些不一致的性质。
在观察核对程序时，记录护士在对照准备好的化疗医嘱进行双重核对过程中发现的所有不一致情况。
瑞士三家医院的肿瘤病房和门诊输液中心。
观察护士的双重核对情况。
在定性分析中，（1）制定了不一致情况的分类系统，（2）由两名研究人员独立应用。
在观察的690次双重核对中，有22次（3.2%）检测到28起与化疗相关的不一致情况。其中一半与医嘱和药品标签之间的信息不匹配有关，另一半是因为护士运用了自己的知识而发现的。75%的不一致情况可追溯到不当医嘱，这些不一致情况导致了33次后续或纠正措施。
在双重核对情况下，通常会审查用药的合理性。此外，双重核对还可纠正用药过程中更早阶段（医嘱开具时）出现的错误。这两个结果为改进用药流程带来了新的机遇。
