Khalil Viviane, Bates Antoinette
Monash University, Melbourne, Australia.
Monash Health, Clayton, Melbourne, Australia.
Ir J Med Sci. 2022 Dec;191(6):2433-2438. doi: 10.1007/s11845-021-02872-0. Epub 2021 Dec 2.
Medication errors remain one of the most common types of incidents reported in Australian hospitals. Studies have reported that for every 10 medication administrations, a medication administration error is likely to occur and reach the patient, potentially contributing to a preventable patient harm.
To assess the impact of a mixed intervention model on medication administration errors in an Australian hospital.
Two types of intervention model (human and system orientated) were implemented through collaboration with key stakeholders (nurses, educators, and policy makers) to reduce medication administration errors across this 650-bed multisite Australian hospital from August 2018 to June 2019. To assess the impact of the mixed intervention model, the total number of reported medication errors and the number of medication administration errors were retrieved from the hospital electronic medication management system for 12 months before (from June 2017 to July 2018) and after (from July 2019 to June 2020) implementation of all interventions.
Implementation of a mixed intervention model through collaboration with stakeholders resulted in significant reduction in the number of medication administration errors, and those with harm (from 68 to 55%, P < 0.0001 and from 12 to 8%, P = 0.0001 respectively). Additionally, the severity of medication administration errors was also reduced (HR 0.562, 95% CI (0.298-1.062)) in the post-intervention phase.
Introducing a mixed intervention model reduces medication administration errors across health settings and has the potential to drive excellence in healthcare.
用药错误仍然是澳大利亚医院报告的最常见的事件类型之一。研究报告称，每进行10次用药操作，就可能发生一次用药错误并影响到患者，这可能导致可预防的患者伤害。
评估一种混合干预模式对澳大利亚一家医院用药错误的影响。
通过与关键利益相关者（护士、教育工作者和政策制定者）合作，实施了两种干预模式（以人员和系统为导向），以减少这家拥有650张床位的澳大利亚多院区医院在2018年8月至2019年6月期间的用药错误。为评估混合干预模式的影响，从医院电子用药管理系统中检索了在所有干预措施实施前（2017年6月至2018年7月）和实施后（2019年7月至2020年6月）12个月内报告的用药错误总数和用药操作错误数量。
通过与利益相关者合作实施混合干预模式，用药操作错误数量以及造成伤害的用药操作错误数量显著减少（分别从68%降至55%，P<0.0001；从12%降至8%，P = 0.0001）。此外，干预后阶段用药操作错误的严重程度也有所降低（风险比0.562，95%置信区间(0.298 - 1.062)）。
引入混合干预模式可减少各医疗机构的用药错误，并有可能推动医疗保健领域的卓越发展。
