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薬物の有害事象のシステム分析. ADE予防研究グループ
L L Leape1, D W Bates, D J Cullen
1Department of Health Policy and Management, Harvard School of Public Health, Boston, MA 02115, USA.
JAMA
|July 5, 1995
まとめ
薬物知識の普及と患者情報へのアクセスにおけるシステム障害は,ほとんどの有害薬物イベント (ADEs) を引き起こします. これらのシステムを改善することで,薬剤の誤差を軽減し,患者の安全性を向上させることができます.
科学分野:
- 医療の質と安全について
- 薬剤の誤差分析について
- 医療システム研究 医療システム研究
背景:
- 薬剤による有害事象 (ADEs) と潜在的有害事象は,患者の安全に対する重大な懸念を代表しています.
- これらのイベントの根本的な原因を理解することは,効果的な予防戦略の開発に不可欠です.
研究 の 目的:
- 薬物の有害事象 (ADEs) と潜在的ADEsにつながるシステム障害,根本的なエラーを特定し,評価する.
- 病院の薬物使用プロセスにおける一般的な全身的弱点を特定する.
主な方法:
- 2つの三級医療病院の11の医療・外科部門で6ヶ月間にわたるイベントのシステム分析を含む前向きなコホート研究.
- 誤りはインタビューを通じて検出され,近接原因と基礎システムの故障によって多学科チームによって分類されました.
主要な成果:
- 334のエラーが特定され,264の予防可能な有害事象および潜在的な有害事象を引き起こしました.
- 16の主要なシステム障害が発見され,薬物知識の普及 (29%) と患者情報の可用性 (18%) が最も一般的であった.
- 7つのシステムの故障は,エラーの78%を占め,改善された情報システムの潜在的な影響を強調しました.
結論:
- 病院スタッフは,薬物使用エラーに関連するシステム障害を特定することに積極的に参加しました.
- 薬物に関する知識の普及と患者情報へのアクセスに関するシステムの欠陥が,エラーの主要な原因であった.
- 薬剤および患者データシステムの強化は,薬剤の誤差を軽減し,患者の安全性を改善するために不可欠です.
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