Aghighi Negar, Aryankhesal Aidin, Raeissi Pouran, Najafpour Zhila
Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran.
Department of Health Care Management, School of Public Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
J Educ Health Promot. 2024 Jan 22;12:422. doi: 10.4103/jehp.jehp_1726_22. eCollection 2023.
Despite efforts to improve patient safety, medical errors (MEs) continue to recur. Proper utilization of reported MEs can be effective in preventing their recurrence. This study investigated the errors reported in 3 years and examined the factors affecting them.
This descriptive analytical study was conducted using the errors reported in 20 hospitals under the auspices of one of Iran's medical universities from 2018 to 2020. All reported errors were investigated by an expert panel.
In total, 6584 reported errors were grouped into four main categories based on the type of error. The highest reported errors were related to the management and treatment procedures. Analyses of the factors influencing medical errors revealed that 15 factors affected the occurrence of errors. An increasing trend of error was found in 9 of the 15 identified factors. Incorrect documenting of the physician's order in the nursing Kardex and noncompliance with the patient identification guide were the highest with 16.03 and 15.47%, respectively.
The most identified factor was the incorrect registration of the physician's prescription on the nursing card; therefore, it seems that the use of computerized physician order entry should be considered. Furthermore, the mere existence and training of patient safety guides cannot help prevent errors. Not only should the underlying causes of errors be carefully identified and investigated but it also requires serious determination to follow the patient's safety instructions from the highest to the lowest levels of the health system.
尽管为提高患者安全做出了努力，但医疗差错仍不断出现。正确利用所报告的医疗差错可有效预防其再次发生。本研究调查了3年期间报告的差错，并分析了影响这些差错的因素。
本描述性分析研究利用了伊朗一所医科大学下属20家医院在2018年至2020年期间报告的差错。所有报告的差错均由一个专家小组进行调查。
根据差错类型，共6584例报告差错被分为四大类。报告差错最多的与管理和治疗程序有关。对影响医疗差错因素的分析表明，有15个因素影响差错的发生。在15个已确定因素中的9个因素中发现差错呈上升趋势。医生医嘱在护理 Kardex 中的记录错误以及未遵守患者身份识别指南的情况最为严重，分别为16.03%和15.47%。
最常见的因素是医生处方在护理卡上的登记错误；因此，似乎应考虑使用计算机化医生医嘱录入系统。此外，仅仅存在患者安全指南并进行培训并不能帮助预防差错。不仅要仔细识别和调查差错的根本原因，而且卫生系统从上到下都需要有认真执行患者安全指示的决心。
