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病院の入院患者の処方誤りの原因:前向きな研究
Bryony Dean1, Mike Schachter, Charles Vincent
1Centre for Practice and Policy, School of Pharmacy, University of London, London, UK. bdean@hhnt.org
Lancet (London, England)
|April 30, 2002
まとめ
処方誤りは,しばしば注意の欠落と規則の不遵守から生じる. 作業量やトレーニングなどの要因に対処することは,患者の安全と医療ミスの削減に不可欠です.
科学分野:
- 医療ミス分析 医療ミス分析
- 医療における人間的要因
- 患者の安全性に関する研究
背景:
- 処方誤差は,医療における患者の被害の重要な原因である.
- 高リスク産業からの既存のヒューマンエラー理論は,処方エラーに広く適用されていません.
- 処方誤りの根本的な原因を理解することは,効果的な予防戦略を開発するために不可欠です.
研究 の 目的:
- 人為的エラー理論を用いて処方エラーの原因を調査する.
- 処方薬における医療ミスに寄与する危険因子を特定する.
- 処方誤りによる患者の被害を減らすための戦略を策定する.
主な方法:
- イギリスの教科病院の薬剤師による88件の潜在的に重大な処方誤りの見込みの特定.
- 44人の処方箋を書いた医師のインタビューで,誤りが見つかりました.
- 既定の人間のエラー理論のレンズを通して発見の分析.
主要な成果:
- ほとんどの処方誤りは,注意の欠落や関連する規則の適用を怠ったことによるものです.
- 特定された危険因子には,労働環境,労働負荷,チームコミュニケーション,処方者福祉,知識のギャップが含まれます.
- 不十分な訓練や階層構造などの組織的要因も,エラーに寄与します.
結論:
- 病院は,薬剤投与の原則について初級医師を訓練し,文書化基準を強制すべきである.
- 処方箋の書き方を重視する文化を創り出し,介入の正式なレビューを行うことが推奨されます.
- 誤りやすい状況の認識と作業負荷の対処は,処方エラーを減らすための鍵です.
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