Crozier Nick, Robinson Elisa, Murtagh Nicole C, Coyne Briana D
University of New Mexico Comprehensive Cancer Center, Albuquerque, NM, USA.
University of Washington-Seattle Campus, UW Medicine, Seattle, WA, USA.
Hosp Pharm. 2024 Apr;59(2):210-216. doi: 10.1177/00185787231207995. Epub 2023 Nov 1.
The Institute for Safe Medication Practice (ISMP) suggests that patient safety reports be addressed with systematic, fail-safe, actions to prevent error recurrence. ISMP's hierarchy of effectiveness of risk reduction strategies places education-related interventions as the least effective and fail-safes at the top. UNM Hospitals creates a positive environment for safety reporting, but often we are limited to education interventions due to resource and technology constraints. This study analyzes the intervention potential and quality of pharmacy-related medication safety reports. One thousand medication-related safety reports from selected time points between 2012 and 2022 were selected. Safety reports were included in our study if they were actionable by the pharmacy department. Each safety report was categorized by type of safety event and given an intervention potential score of 1 to 10 (1 indicating education-only, 10 being forcing function) by 2 student pharmacists and 1 pharmacy director based on their potential place on ISMP's hierarchy. Safety report quality was graded based on professionalism, organization, clarity, and completeness. A standardized evaluation form was used for evaluation for all elements. Six-hundred-sixty-five safety reports were pharmacy-related and evaluated by all 3 study team members for analysis. The 3 most common pharmacy-related safety reports were medication delivery, inappropriate order verification, and transcribing errors which accounted for over half of the reports (59.5%) and on average the intervention potential score of these types of safety reports was education only. Overall, safety reports were limited to a maximum actionability of education-only 75.4% of the time. Safety reports were found to be professionally written and well organized. The actionability of most pharmacy-related medication safety reports was limited to low leverage interventions likely because high leverage solutions were addressed with systematic change and did not recur. Errors limited to education interventions repeated and this increased relative counts of low leverage actionability of safety reports. The ISMP hierarchy of effectiveness of risk-reduction strategies is an important guide to intervening in medication-related safety events, but pharmacy staff should not be discouraged if most of the safety reports cannot be addressed through high-leverage interventions.
安全用药实践研究所（ISMP）建议，应采取系统的、具有故障安全功能的措施来处理患者安全报告，以防止错误再次发生。ISMP的风险降低策略有效性层次结构将与教育相关的干预措施列为最无效的措施，而将故障安全措施置于首位。新墨西哥大学医院为安全报告创造了积极的环境，但由于资源和技术限制，我们通常仅限于教育干预措施。本研究分析了与药学相关的用药安全报告的干预潜力和质量。从2012年至2022年的选定时间点选取了1000份与用药相关的安全报告。如果药学部门可以对安全报告采取行动，则将其纳入我们的研究。每份安全报告按安全事件类型进行分类，并由2名学生药剂师和1名药房主任根据其在ISMP层次结构中的潜在位置给予1至10分的干预潜力评分（1表示仅教育，10表示强制功能）。安全报告质量根据专业性、组织性、清晰度和完整性进行分级。使用标准化评估表对所有要素进行评估。665份安全报告与药学相关，并由所有3名研究团队成员进行评估以进行分析。3种最常见的与药学相关的安全报告是药物交付、不当医嘱核实和转录错误，占报告总数的一半以上（59.5%），并且这些类型的安全报告的平均干预潜力评分仅为教育。总体而言，75.4%的时间里安全报告仅限于仅教育的最大可操作性。发现安全报告撰写专业且组织良好。大多数与药学相关的用药安全报告的可操作性仅限于低影响力干预措施，这可能是因为高影响力解决方案通过系统变革得到解决且未再次发生。限于教育干预措施的错误会重复出现，这增加了安全报告低影响力可操作性的相对数量。ISMP的风险降低策略有效性层次结构是干预与用药相关安全事件的重要指南，但如果大多数安全报告无法通过高影响力干预措施解决，药学人员也不应气馁。
