药物错误只有在特定的背景下才有意义:对药物错误的上下文敏感理解
Ross Koppel1, Joel L Telles2, Diane G Schwartz3
1University of Pennsylvania, Phila., PA, USA.
Studies in health technology and informatics
|May 13, 2025
概括
药物错误占医院医疗错误的20%. 研究应该检查处方和管理中的错误,这些错误占所有药物错误的近一半.
科学领域:
- 医疗安全 医疗安全
- 改善医疗保健质量 改善医疗保健质量
- 患者护理 患者护理
背景情况:
- 药物错误占医院环境中所有医疗错误的很大一部分,占总数的20%.
- 错误率在药物治疗过程的各个阶段大大不同,包括处方,分发,施用,摄入和监测.
研究的目的:
- 通过在药物过程的特定背景下检查药物错误来提高对药物错误的理解.
- 在药物管理的每个阶段审查错误的类型,来源和贡献因素.
- 分析影响遵守"药物管理的5个权利"的因素.
主要方法:
- 关于药物错误的现有文献的全面审查.
- 错误的分类基于药物过程中的背景 (处方,转录,分发,管理,摄入,监测).
- 对每个已识别的上下文的错误类型,来源和影响因素进行分析.
主要成果:
- 处方和服药阶段与药物错误率最高相关,每个阶段贡献了所有错误的49%.
- 转录 (1%),分发 (12%),摄入 (3%) 和监测 (5%) 的错误率明显较低.
- 错误率的变化凸显了药物管理途径中的特定漏洞.
结论:
- 了解药物错误需要一种特定于环境的方法,重点关注处方和管理等高风险阶段.
- 进一步研究"药物管理的5个权利"及其相关的错误因素对于开发有针对性的干预措施至关重要.
- 实施减轻处方和管理错误的策略可以显著提高医院的患者安全.
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