School of Medicine, University of Dundee, Dundee, UK
Gynaecology, Ninewells Hospital, Dundee, UK.
BMJ Open Qual. 2021 Sep;10(3). doi: 10.1136/bmjoq-2020-001277.
It is estimated that 1 in 10 hospital inpatients in Scotland have experienced a medication error. In our unit, an audit in 2019 identified documentation of as-required prescriptions on drug Kardexes as an important target for improvement. This project aimed to reduce the percentage of these errors to <5% in the ward in 6 months.Weekly point prevalence surveys were used to measure medication error rates over a 12-week baseline period. Errors in route, frequency of dose and maximum dose accounted for >80% of all prescribing errors. The intervention was a poster reminder about the three most common errors linked to standards for prescribing pain medication. Barriers to change were identified through inductive thematic analysis of semistructured interviews with five ward doctors and two staff nurses.In the 6 weeks after intervention, our run chart showed a shift in maximum dose errors per patient, which fell from 75% to 26%. However, route and frequency errors remained high at >70% per patient. Most of these errors were due to use of abbreviations, and qualitative interviews revealed that senior doctors and nurses believed that these abbreviations were safe. We found some evidence from national guidelines to support these beliefs.Overall, the intervention was associated with decreased prevalence of patients without a maximum dose written on their prescription, but lack of space on drug prescriptions was identified as a key barrier to further improvement in both maximum dose and abbreviation errors.
据估计，苏格兰每 10 名住院患者中就有 1 名经历过用药错误。在我们的科室，2019 年的一次审计将 Kardex 上按需处方的记录确定为一个重要的改进目标。该项目旨在在 6 个月内将该病房的这些错误百分比降低到<5%。我们使用每周时点患病率调查来衡量 12 周基线期内的用药错误率。在所有用药错误中，给药途径、剂量频率和最大剂量错误超过 80%。干预措施是一张海报，提醒与疼痛药物开具标准相关的三种最常见错误。通过对 5 名病房医生和 2 名护士进行半结构化访谈的归纳主题分析，确定了变革的障碍。在干预后的 6 周内，我们的运行图表显示每位患者的最大剂量错误有所减少，从 75%降至 26%。然而，每位患者的给药途径和频率错误仍高达>70%。这些错误大多是由于使用缩写造成的，定性访谈显示，资深医生和护士认为这些缩写是安全的。我们从国家指南中找到了一些支持这些信念的证据。总的来说，干预措施与没有在处方上写明最大剂量的患者比例下降有关，但处方上缺乏空间被确定为进一步改善最大剂量和缩写错误的关键障碍。
