对药物不良事件的系统分析. ADE预防研究小组研究小组
L L Leape1, D W Bates, D J Cullen
1Department of Health Policy and Management, Harvard School of Public Health, Boston, MA 02115, USA.
JAMA
|July 5, 1995
概括
药物知识传播和患者信息获取方面的系统故障导致了大多数不良药物事件 (ADEs). 改进这些系统可以减少药物错误,提高患者的安全.
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
- 卫生系统研究 卫生系统研究
背景情况:
- 药物不良事件 (ADE) 和潜在的ADE构成了严重的患者安全问题.
- 了解这些事件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:
- 识别和评估导致药物不良事件 (ADEs) 和潜在的ADEs的系统故障,潜在的错误.
- 确定医院药物使用过程中常见的系统性缺陷.
主要方法:
- 一项前性队列研究,涉及六个月内在两个三级护理医院的11个医疗和外科病房中对事件的系统分析.
- 通过采访检测出错误,并由多学科团队根据近距离原因和潜在系统故障进行分类.
主要成果:
- 确定了334个错误,导致264个可预防的ADE和潜在的ADE.
- 发现了16个主要系统故障,其中药物知识传播 (29%) 和患者信息可用性 (18%) 是最常见的.
- 七个系统故障占78%的错误,突出了改进的信息系统的潜在影响.
结论:
- 医院工作人员积极参与识别与药物使用错误相关的系统故障.
- 传播药物知识和获取患者信息的系统缺陷是导致错误的主要原因.
- 加强药物和患者数据系统对于减少药物错误和提高患者安全至关重要.
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