Reducing Medication Errors
Tóm tắt
Since the Institute of Medicine’s report, To Err Is Human, and the subsequent publication, Crossing the Quality Chasm, the subject of reducing medical errors has gained considerable attention from patients, healthcare providers, employers and government organisations in the US. Most nonoperative errors are related to medications. Medication errors lead not only to negative repercussions subjectively experienced by both the patient and the healthcare staff, but also to additional expenditures due to complications. Education, adapting new safety systems and technology, and having clinical pharmacists play a larger role in the medication process can all help in solving the problem of medication errors. Designing and executing a rational system to reduce medication errors is particularly germane in the current era of increased demands for quality healthcare in the setting of cost-containment pressures. In the Delaware Valley (Philadelphia and surrounding area) of Pennsylvania, USA, a consortium of healthcare providers in cooperation with the Health Care Improvement Foundation (HCIF), and two non-profit oganisations — the ECRI (formerly the Emergency Care Research Institute) and the Institute for Safe Medication Practices (ISMP) — have combined to establish and promote safe medication practices under a programme known as the Regional Medication Safety Program for Hospitals. At the core of the programme are 16 medication safety goals, which centre on establishing an institutional culture of safety, modifying infrastructure and clinical practice to reflect this culture, and using technology to facilitate these changes. It is believed that this rational campaign to improve patient safety may serve as a paradigm for other regions around the world.
Tài liệu tham khảo
Wilson RM, Runciman WB, Gibberd RW, et al. The quality in Australian health care study. Med J Aust 1995; 163: 458–71
Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. BMJ 2001 Mar 3; 322(7285): 517–9
Sinclair A. Medical error and patient safety. CMAJ 2001 Oct 16; 165(8): 1085
Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer health system. Washington (DC): National Academy Press, 2000
Committee on Quality Health Care in America, Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington (DC): National Academy Press, 2001
Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med 1991 Feb 7; 324(6): 370–6
Leape LL, Brennan TA, Laird NM, et al. Nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II. N Engl J Med 1991 Feb 7; 324(6): 377–84
Thomas EJ, Studdert DM, Burstin HR, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care 2000 Mar, 71
Johnson WG, Brennan TA, Newhouse JP, et al. The economic consequences of medical injuries: implications for a no-fault insurance plan. JAMA 1992 May 13; 267(18): 2487–92
Thomas EJ, Studdert DM, Newhouse JP, et al. Costs of medical injuries in Utah and Colorado. Inquiry 1999 Fall; 36: 255–64
McDonald CJ, Weiner M, Hui SL. Deaths due to medical errors are exaggerated in Institute of Medicine report. JAMA 2000 Jul 5; 284(1): 93–5
Brennan TA. The institute of medicine report on medical errors: could it do harm? N Engl J Med 2000 Apr 13; 342(15): 1123–5
Leape LL. Institute of medicine medical error figures are not exaggerated. JAMA 2000 Jul 5; 284(1): 95–7
Phillips J, Beam S, Brinker A, et al. Retrospective analysis of mortalities associated with medication errors. Am J Health Syst Pharm 2001 Oct 1; 58(19): 1835–41
Young D. More hospitals report medication errors, but USP finds few changes. Am J Health Syst Pharm 2002 Jul; 59(13): 1233
Olsson S. The role of the WHO programme on international drug monitoring in coordinating worldwide drug safety efforts. Drug Saf 1998 Jul; 19(1): 1–10
Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events: implications for prevention. ADE Prevention Study Group. JAMA 1995 Jul 5; 274(1): 29–34
Cullen DJ, Sweitzer BJ, Bates DW, et al. Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units. Crit Care Med 1997 Aug; 25(8): 1289–97
Kozer E, Scolnick D, Keays T, et al. Large errors in the dosing of medications for children. N Engl J Med 2002 Apr 11; 346(15): 1175–6
Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA 2001 Apr 25; 285(16): 2114–20
Denham MJ, Barnett NL. Drug therapy and the older person, role of the pharmacist. Drug Saf 1998 Oct; 19(4): 243–50
Needleman J, Buerhaus P, Mattke S, et al. Nurse-staffing levels and the quality of care in hospitals. N Engl J Med 2002 May 30; 346(22): 1715–22
Rosebraugh CJ, Honig PK, Yasuda SU, et al. Centers for education and research on therapeutics report: survey of medication errors education during undergraduate and graduate medical education in the United States. Clin Pharmacol Ther 2002 Jan; 71(1): 4–10
Caldwell NA, Hughes DK. How to decrease errors in dose [letter]. J Pediatr 2000 Jul; 137(1): 142
Lambert BL, Lin SJ, Chang KY, et al. Similarity as a risk factor in drug-name confusion errors: the look-alike (orthographic) an sound-alike (phonetic) model. Med Care 1999 Dec; 37(12): 1214–25
Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. JAMA 1995 Jul 5; 274(1): 35–43
Bates DW, Leape LL, Cullen DJ, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA 1998 Oct 21; 280(15): 1311–6
Young D. Veterans Affairs bar-code-scanning system reduces medication errors. Am J Health Syst Pharm 2002 Apr 1; 59(7): 591–2
Thompson KK. Bar-coding a must for patient safety. Am J Health Syst Pharm 2002 Apr 1; 59(7): 667–8
Thompson CA. FDA to develop rules for mandatory bar-code labels: bar codes seen as part of error-reduction strategy. Am J Health Syst Pharm 2002 Jan 1; 59(2): 107, 112
Leape LL, Cullen DJ, Clapp MD, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA 1999 Jul 21; 281(3): 267–70
Krupicka MI, Bratton SL, Sonnenthal K, et al. Impact of a pediatric clinical pharmacist in the pediatric intensive care unit. Crit Care Med 2002 Apr; 30(4): 919–21