Huang Huiling, Sunku Srivatsava, Ong Hui Shan, Chan Jonathan Kim Yang, Sim Guek Gwee
Department of Emergency Medicine, Changi General Hospital, Singapore
Department of Emergency Medicine, Changi General Hospital, Singapore.
BMJ Open Qual. 2024 Dec 20;13(4):e003141. doi: 10.1136/bmjoq-2024-003141.
Medication errors continue to pose a significant risk to patient safety, accounting for half of the avoidable harm in healthcare systems around the world. In emergency departments (EDs), factors such as high patient loads and emergent nature of care increase the likelihood of such errors. An audit conducted at the ED of Changi General Hospital Singapore from January 2019 to July 2022 revealed that the duplicate therapy error comprised 31% of all reported medication errors. Therapeutic duplication occurs when the same or pharmacologically equivalent agents are prescribed concurrently to a patient. These errors not only jeopardise patient safety but also place additional strain on healthcare resources and lead to stress among the staff involved.This quality improvement (QI) project aims to reduce duplicate therapy error by 50% 3 months post-intervention at the ED. Beginning in August 2022 and continuing through December 2023, the project followed a structured approach comprising four phases: problem identification, identifying root causes, developing of targeted interventions and ensuring sustainability. Phase 1 involved an audit from January 2019 to July 2022 to determine the extent and types of medication errors in the ED. In phase 2, a root cause analysis (RCA) of the medication error identified key issues such as system knowledge deficits, inadequate IT processes, environment, policies and procedures and gaps in care coordination. Based on these findings, targeted interventions were developed and implemented in phase 3. Phase 4 focused on sustaining improvements through ongoing audits.The QI project successfully met its goal of reducing duplicate therapy error rates by 50% post-intervention. Additionally, it completely eliminated duplicate therapy errors in certain medication categories.In conclusion, through targeted interventions, active engagement of relevant stakeholders and ongoing efforts to sustain and enhance improvement, a safer healthcare environment can be achieved for patients.
用药错误继续对患者安全构成重大风险，在全球医疗系统中，此类错误占可避免伤害的一半。在急诊科，患者数量多以及护理工作的紧急性质等因素增加了此类错误发生的可能性。对新加坡樟宜综合医院急诊科在2019年1月至2022年7月期间进行的一项审计显示，重复治疗错误占所有报告的用药错误的31%。当同时给患者开具相同或药理学等效的药物时，就会发生治疗重复。这些错误不仅危及患者安全，还会给医疗资源带来额外压力，并导致相关工作人员产生压力。这个质量改进（QI）项目旨在干预后3个月内将急诊科的重复治疗错误减少50%。该项目从2022年8月开始，持续到2023年12月，采用了一种结构化方法，包括四个阶段：问题识别、确定根本原因、制定有针对性的干预措施以及确保可持续性。第一阶段涉及对2019年1月至2022年7月期间的审计，以确定急诊科用药错误的程度和类型。在第二阶段，对用药错误进行根本原因分析（RCA），确定了关键问题，如系统知识不足、信息技术流程不完善、环境、政策和程序以及护理协调方面的差距。基于这些发现，在第三阶段制定并实施了有针对性的干预措施。第四阶段专注于通过持续审计来维持改进。该QI项目成功实现了干预后将重复治疗错误率降低50%的目标。此外，它完全消除了某些药物类别中的重复治疗错误。总之，通过有针对性的干预措施、相关利益攸关方的积极参与以及持续维持和加强改进的努力，可以为患者实现更安全的医疗环境。
