解决药物错误:系统方法如何改善患者安全
Sonja Guntschnig1, Renata Barbosa2, Helena Jenzer3
1Pharmacy, Ulster University Faculty of Life and Health Sciences, Coleraine, UK guntschnig.sonja@gmail.com.
药物错误会伤害患者,通常是由于系统故障. 实施强有力的治理,政策和自动化可以显著减少这些可预防的错误,并改善欧洲的患者安全.
科学领域:
- 医疗保健的质量和安全
- 药物监督 药物监督 药物监督
- 卫生系统研究 卫生系统研究
背景情况:
- 药物错误是可预防的患者伤害的重要原因,大约影响30人中的1人.
- 很大一部分药物错误会导致严重的不良后果,需要紧急干预.
研究的目的:
- 提出可持续的战略,以减少欧洲的药物错误.
- 采用系统方法来识别和解决药物错误的根本原因.
主要方法:
- 分析了89份匿名的药物错误报告和专家实践数据.
- 将根本原因分为系统级和个人级的错误.
- 对PubMed和Embase的文献审查,以确定药物安全方面的标准和差距.
主要成果:
- 治理缺陷和不一致的法律标准实施是导致药物错误的主要原因.
- 普遍存在的系统级问题包括监督不足,人力不足和技术基础设施不佳.
- 还发现了个人错误,通常是由于认知缺陷,以及安全实践的变化.
结论:
- 强有力的治理,全面的政策和增强的安全文化对于预防药物错误至关重要.
- 自动化和改进的人机界面可以减轻主动故障并提高系统可靠性.
- 系统思维方法,强化立法和更好的资源配置对于减少药物错误和提高患者安全至关重要.
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