Leape L L, Bates D W, Cullen D J, Cooper J, Demonaco H J, Gallivan T, Hallisey R, Ives J, Laird N, Laffel G
Department of Health Policy and Management, Harvard School of Public Health, Boston, MA 02115, USA.
JAMA. 1995 Jul 5;274(1):35-43.
To identify and evaluate the systems failures that underlie errors causing adverse drug events (ADEs) and potential ADEs.
Systems analysis of events from a prospective cohort study.
All admissions to 11 medical and surgical units in two tertiary care hospitals over a 6-month period.
Errors, proximal causes, and systems failures.
Errors were detected by interviews of those involved. Errors were classified according to proximal cause and underlying systems failure by multidisciplinary teams of physicians, nurses, pharmacists, and systems analysts.
During this period, 334 errors were detected as the causes of 264 preventable ADEs and potential ADEs. Sixteen major systems failures were identified as the underlying causes of the errors. The most common systems failure was in the dissemination of drug knowledge, particularly to physicians, accounting for 29% of the 334 errors. Inadequate availability of patient information, such as the results of laboratory tests, was associated with 18% of errors. Seven systems failures accounted for 78% of the errors; all could be improved by better information systems.
Hospital personnel willingly participated in the detection and investigation of drug use errors and were able to identify underlying systems failures. The most common defects were in systems to disseminate knowledge about drugs and to make drug and patient information readily accessible at the time it is needed. Systems changes to improve dissemination and display of drug and patient data should make errors in the use of drugs less likely.
识别和评估导致药物不良事件（ADEs）及潜在ADEs的差错背后的系统故障。
对一项前瞻性队列研究中的事件进行系统分析。
两家三级护理医院11个内科和外科科室在6个月期间的所有入院患者。
差错、近端原因和系统故障。
通过对相关人员的访谈来发现差错。由医生、护士、药剂师和系统分析师组成的多学科团队根据近端原因和潜在系统故障对差错进行分类。
在此期间，共检测到334起差错，这些差错导致了264起可预防的ADEs及潜在ADEs。确定了16个主要系统故障为差错的根本原因。最常见的系统故障是药物知识传播方面的问题，尤其是向医生传播，占334起差错中的29%。患者信息（如实验室检查结果）获取不充分与18%的差错有关。7个系统故障占差错的78%；所有这些都可以通过更好的信息系统得到改善。
医院工作人员愿意参与药物使用差错的检测和调查，并能够识别潜在的系统故障。最常见的缺陷在于药物知识传播系统以及在需要时无法方便获取药物和患者信息的系统。改善药物和患者数据传播与展示的系统变革应能减少药物使用中的差错。
