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医院住院患者处方错误的原因:一项前性研究
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
概括
处方错误往往源于注意力缺失和规则不遵守. 解决工作量和培训等因素对于患者安全和减少医疗错误至关重要.
科学领域:
- 医学错误分析 医学错误分析
- 医疗保健中的人类因素
- 患者安全研究的研究.
背景情况:
- 处方错误是医疗保健中患者伤害的重要原因之一.
- 来自高风险行业的现有人为错误理论尚未广泛应用于处方错误.
- 了解处方错误的根本原因对于制定有效的预防策略至关重要.
研究的目的:
- 用人类错误理论调查处方错误的原因.
- 识别导致药物处方医疗错误的危险因素.
- 为减少因处方错误造成的患者伤害的策略提供信息.
主要方法:
- 在英国一家教学医院的药剂师对88个可能严重的处方错误的前景识别.
- 采访了44名处方医生,发现他们犯了错误.
- 通过既定的人类错误理论的透视来分析研究结果.
主要成果:
- 大多数处方错误是由于注意力不集中或未能应用相关规则造成的.
- 确定的风险因素包括工作环境,工作负载,团队沟通,处方者福祉和知识差距.
- 组织因素,如不充分的培训和层次结构,也会导致错误.
结论:
- 医院应培训初级医生使用药物剂量原则,并执行文档标准.
- 建议建立一种文化,重视处方书写和正式审查干预措施.
- 意识到容易出错的情况和处理工作负载是减少处方错误的关键.
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