Valkonen Ville, Haatainen Kaisa, Saano Susanna, Tiihonen Miia
School of Pharmacy, University of Eastern Finland Kuopio Finland.
Department of Nursing Science University of Eastern Finland Kuopio Finland.
Health Sci Rep. 2024 Sep 18;7(9):e70077. doi: 10.1002/hsr2.70077. eCollection 2024 Sep.
Medication errors (MEs) are a significant source of preventable harm in patient care. Voluntary incident reporting and ME reporting systems are essential for managing medication safety. Analyzing aggregated ME reports instead of individual reports can reveal organizational risks. Organizational culture influences reporting activity and the effectiveness of safety improvements depends on their system-focus. This study uses aggregated ME reports to investigate the ME management process and reporting culture in medication safety. It aims to create a hierarchy for ME improvement actions and analyze their strength and management flow in aggregated reports.
A retrospective, cross-sectional study was conducted to review improvement proposals and actions of ME reports in a Finnish tertiary hospital in 2017-2021. The improvement proposals and actions were categorized into strength classes during three stages: reporter proposals, manager proposals, and documented actions. The report management flow was analyzed. Descriptive statistics were used to describe the characteristics and the chi-squared test for categorical variables in the statistical analysis.
A new strength classification hierarchy was created with three classes and corresponding numerical values: "strong (3)," "medium (2)," and "weak (1)" Additionally, categories for "no action (0)" and "vague (0)" were included. Out of 5463 ME reports analyzed, improvement proposals and actions were predominantly weak, ranging from 23.4% to 54.2% across different stages of the management process. A significant proportion had no action included (20.5-49.1%) or were vague (4.2-20.6%).
Analyzing the strength of improvement proposals and actions in aggregated ME reports provides new insights into reporting culture and the ME management. The new combined strength classification hierarchy is a suitable tool for this analysis.
用药错误（MEs）是患者护理中可预防伤害的重要来源。自愿事件报告和用药错误报告系统对于管理用药安全至关重要。分析汇总的用药错误报告而非个别报告可以揭示组织风险。组织文化影响报告活动，安全改进的有效性取决于其系统重点。本研究使用汇总的用药错误报告来调查用药安全中的用药错误管理过程和报告文化。其目的是为用药错误改进行动创建一个层次结构，并分析其在汇总报告中的力度和管理流程。
进行了一项回顾性横断面研究，以审查2017 - 2021年芬兰一家三级医院用药错误报告的改进建议和行动。在三个阶段将改进建议和行动分类为力度等级：报告者建议、管理者建议和记录在案的行动。分析了报告管理流程。描述性统计用于描述特征，统计分析中对分类变量使用卡方检验。
创建了一个新的力度分类层次结构，有三个等级及相应数值：“强（3）”、“中（2）”和“弱（1）”。此外，还包括“无行动（0）”和“模糊（0）”类别。在分析的5463份用药错误报告中，改进建议和行动主要为弱，在管理过程的不同阶段占比从23.4%到54.2%不等。很大一部分没有包括行动（20.5 - 49.1%）或很模糊（4.2 - 20.6%）。
分析汇总的用药错误报告中改进建议和行动的力度为报告文化和用药错误管理提供了新见解。新的综合力度分类层次结构是进行此分析的合适工具。
