Cooper M C
City Hospital (NHS Trust), Birmingham, England.
J Adv Nurs. 1995 Mar;21(3):487-91. doi: 10.1111/j.1365-2648.1995.tb02731.x.
The literature reveals that errors of drug administration are a widely distributed and common occurrence. The frequency of errors and their underlying causes are discussed, and the literature is surveyed to determine reasons for mistakes and possible remedial measures. Ideas are drawn from industrial sources to describe a model of preventing mistakes at source, by making errors impossible. The ideas of Crosby and Shingo are discussed and a 'zero defects philosophy' is described and developed. This paper attempts to determine if this quality model developed and used in industry can be transferred to the health service, and concludes that it needs adaptation and cautious application. Recommendations are made for improved practices and improvements, both clinical and managerial. The author recommends a multidisciplinary review of all practices and systems to develop a radically different procedure with no drug errors as its aim. It is questioned whether this is possible in the present health service environment, as this would require sustained management commitment to both the idea and the quality system. However, the author believes that some of the principles can be applied as individual quality initiatives.
文献表明，给药错误广泛存在且很常见。文中讨论了错误发生的频率及其潜在原因，并对相关文献进行了调研，以确定出错原因和可能的补救措施。借鉴行业资料中的观点，描述了一种从源头上预防错误的模式，即让错误不可能发生。文中讨论了克罗斯比和新乡重夫的观点，并阐述和发展了“零缺陷理念”。本文试图确定这种在行业中开发和使用的质量模式能否应用于医疗服务领域，并得出结论认为需要进行调整并谨慎应用。文中针对临床和管理方面的改进实践与改进提出了建议。作者建议对所有实践和系统进行多学科审查，以制定一个以无用药错误为目标的截然不同的程序。有人质疑在当前的医疗服务环境中这是否可行，因为这需要管理层持续致力于该理念和质量体系。然而，作者认为其中一些原则可作为个体质量改进措施加以应用。
