Betz R P, Levy H B
Am J Hosp Pharm. 1985 Aug;42(8):1724-32.
A system is described for reporting medication errors according to practitioner and type and using these data as part of a departmental quality-assessment program. Types of errors committed in prescribing, in dispensing, and in administering drugs in a teaching hospital were listed. Prescribers' and pharmacists' reports of errors committed. Data on dispensing errors by 16 staff pharmacists were collected over a 12-month period in 1982-83, and data on prescribing by resident physicians were collected during three separate one-month periods. For each pharmacist, data on dispensing errors were compiled monthly. Pharmacists were counseled if they had a large number of errors in one category, a high total number of errors, or a substantial number of errors in a single category over several months. Likewise, physicians who committed more errors than their department's mean were counseled by the clinical chairman. After 12 months, each pharmacist's monthly error rate was compared with the departmental average. The number of dispensing errors reported during the study period (average 60.7 per month for the department) was lower than expected. Serious prescribing errors were minimal. In spite of probable underreporting of errors in this voluntary system, these methods of classifying medication errors by type and practitioner group and of recording error rates were useful tools for monitoring and improving performance of pharmacists and prescribers.
描述了一种根据从业者和类型报告用药错误并将这些数据用作部门质量评估计划一部分的系统。列出了教学医院在开处方、配药和给药过程中出现的错误类型。开处方者和药剂师报告所犯的错误。1982 - 1983年的12个月期间收集了16名药剂师的配药错误数据，住院医师的处方数据则在三个单独的一个月期间收集。对于每位药剂师，每月汇总配药错误数据。如果药剂师在某一类别的错误数量较多、错误总数较高或在几个月内某一类别出现大量错误，就会得到指导。同样，犯错多于所在科室平均水平的医生会受到临床主任的指导。12个月后，将每位药剂师的每月错误率与科室平均水平进行比较。研究期间报告的配药错误数量（科室平均每月60.7次）低于预期。严重的开处方错误极少。尽管在这个自愿报告系统中可能存在错误报告不足的情况，但这些按类型和从业者群体对用药错误进行分类以及记录错误率的方法，对于监测和提高药剂师和开处方者的工作表现是有用的工具。
