Mutair Abbas Al, Alhumaid Saad, Shamsan Abbas, Zaidi Abdul Rehman Zia, Mohaini Mohammed Al, Al Mutairi Alya, Rabaan Ali A, Awad Mansour, Al-Omari Awad
Research Center, Almoosa Specialist Hospital, Al-Ahsa 36342, Saudi Arabia.
College of Nursing, Princess Norah Bint Abdulrahman University, Riyadh 12214, Saudi Arabia.
Medicines (Basel). 2021 Aug 27;8(9):46. doi: 10.3390/medicines8090046.
Population-based studies from several countries have constantly shown excessively high rates of medication errors and avoidable deaths. An efficient medication error reporting system is the backbone of reliable practice and a measure of progress towards achieving safety. Improvement efforts and system changes of medication error reporting systems should be targeted towards reductions in the likelihood of injury to future patients. However, the aim of this review is to provide a summary of medication errors reporting culture, incidence reporting systems, creating effective reporting methods, analysis of medication error reports, and recommendations to improve medication errors reporting systems.
Electronic databases (PubMed, Ovid, EBSCOhost, EMBASE, and ProQuest) were examined from 1 January 1998 to 30 June 2020. 180 articles were found and 60 papers were ultimately included in the review. Data were mined by two reviewers and verified by two other reviewers. The search yielded 684 articles, which were then reduced to 60 after the deletion of duplicates via vetting of titles, abstracts, and full-text papers.
Studies were principally from the United States of America and the United Kingdom. Limited studies were from Canada, Australia, New Zealand, Korea, Japan, Greece, France, Saudi Arabia, and Egypt. Detection, measurement, and analysis of medication errors require an active rather than a passive approach. Efforts are needed to encourage medication error reporting, including involving staff in opportunities for improvement and the determination of root cause(s). The National Coordinating Council for Medication Error Reporting and Prevention taxonomy is a classification system to describe and analyze the details around individual medication error events.
A successful medication error reporting program should be safe for the reporter, result in constructive and useful recommendations and effective changes while being inclusive of everyone and supported with required resources. Health organizations need to adopt an effectual reporting environment for the medication use process in order to advance into a sounder practice.
来自多个国家的基于人群的研究不断表明，用药错误率和可避免的死亡率过高。高效的用药错误报告系统是可靠医疗实践的支柱，也是衡量实现医疗安全进展的一项指标。用药错误报告系统的改进工作和系统变革应以降低未来患者受到伤害的可能性为目标。然而，本综述的目的是总结用药错误报告文化、发病率报告系统、创建有效报告方法、用药错误报告分析以及改进用药错误报告系统的建议。
检索了1998年1月1日至2020年6月30日的电子数据库（PubMed、Ovid、EBSCOhost、EMBASE和ProQuest）。共找到180篇文章，最终60篇论文被纳入本综述。数据由两名评审人员挖掘，并由另外两名评审人员核实。检索共得到684篇文章，通过对标题、摘要和全文论文进行审核删除重复项后，最终缩减至60篇。
研究主要来自美国和英国。来自加拿大、澳大利亚、新西兰、韩国、日本、希腊、法国、沙特阿拉伯和埃及的研究有限。用药错误的检测、测量和分析需要积极而非被动的方法。需要努力鼓励报告用药错误，包括让工作人员参与改进机会和确定根本原因。国家用药错误报告和预防协调委员会分类法是一个用于描述和分析单个用药错误事件详细情况的分类系统。
一个成功的用药错误报告计划应对报告者安全，产生建设性和有用的建议以及有效的变革，同时包容所有人并获得所需资源的支持。卫生组织需要为用药过程采用有效的报告环境，以推进到更完善的实践中。
