通过使用迷你根源原因分析和行动来减少因药物错误而导致的无害伤害事件
Ghada Hussain Al Mardawi1, Rajkumar Rajendram2,3, Souzan Mohammed Alowesie1
1Department of Quality Improvement, King Abdulaziz Medical City, King Abdulaziz International Medical Research Center, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia.
Global journal on quality and safety in healthcare
|June 1, 2023
概括
一个小型根源原因分析 (mini-RCA2) 通过提供结构化审查过程,有效地减少了药物错误的复发. 这项质量改进倡议对患者安全和医疗保健组织产生了显著的好处,尽管相关的时间和成本.
科学领域:
- 改善医疗保健质量 改善医疗保健质量
- 患者安全 患者安全
- 药物错误分析 药物错误分析
背景情况:
- 完整的根本原因分析 (RCA) 是对哨兵事件的资源密集型.
- 需要有效的方法来解决不那么严重的药物错误.
- 质量改进项目可以将RCA适应更广泛的应用.
研究的目的:
- 评估微型根本原因分析 (mini-RCA2) 过程对药物错误造成伤害但不是哨戒事件的有效性.
- 为了确定迷你RCA2对类似药物错误的复发的影响.
- 估计与小型RCA2干预相关的时间和劳动力成本.
主要方法:
- 针对导致伤害的药物错误 (不包括哨兵事件) 实施了迷你根本原因分析 (迷你RCA2) 过程.
- 类似的药物错误的发生率在mini-RCA2实施前后进行了比较.
- 从安全报告系统收集数据,并估计了成本.
主要成果:
- 调查了七个药物错误,确定了39个系统故障,导致了42个建议 (22个实施).
- 类似危害事件的复发率从7 (0.11%) 减少到0 (p=0.016),完全实施的结果从9 (0.21%) 减少到0 (p=0.007).
- 干预需要251个小时,成本为34181沙尔阿拉伯卢比 (8256美元).
结论:
- 迷你RCA2提供了一个结构化,高效的流程来管理和减少药物错误.
- 该干预措施成功地减少了类似药物错误的复发,提高了患者的安全性.
- 尽管投入了大量资源,但mini-RCA2的好处超过了医疗机构的成本.
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