高风险的药物错误:英国国家报告和学习系统的洞察力
Abdulrhman Alrowily1, Khalid Alfaraidy1, Saleh Almutairi1
1King Fahad Military Medical Complex, Dhahran 31932, Saudi Arabia.
Exploratory research in clinical and social pharmacy
|December 31, 2024
概括
英国的患者安全是一个问题,胰岛素错误在高风险药物中最常见. 提高药物安全性需要更好的药物检查和IT解决方案.
科学领域:
- 医疗保健的质量和安全
- 药物错误分析 药物错误分析
- 患者风险管理 患者风险管理
背景情况:
- 在医疗保健系统中,患者安全至关重要.
- 医疗错误,特别是高风险药物,在英国越来越令人担忧.
- 研究这些错误的性质对于改进至关重要.
研究的目的:
- 以回顾分析英国患者安全事件.
- 使用国家报告和学习系统 (NRLS) 调查涉及高风险药物的错误.
主要方法:
- 追溯分析1500份NRLS患者安全报告 (2015年1月1日 - 2015年12月31日).
- 事件分为阿片类药物,胰岛素和抗凝固剂.
- 使用Excel®和演推理进行主题分析.
主要成果:
- 与阿片类药物和抗凝血剂相比,与胰岛素有关的事件显示出最高的风险和频率.
- 错误源于管理,处方和发行问题.
- 导致因素包括药物检查不足,沟通不良和员工工作量高.
结论:
- 国家实验室安全数据库是患者安全研究的宝贵资源.
- 结果可以为减少高风险药物错误的措施提供信息.
- 信息技术可以通过过程跟踪来提高药物安全性.
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