An Investigation of Adverse Events in Medication Processes by HFACS and Conditional Probability

被引：1

作者：

Hsieh, Min-chih ^{[1
]}

Lo, Y. C. ^{[1
]}

Wang, E. M. -Y. ^{[1
]}

Fang, Y. H. ^{[2
]}

Kung, W. C. ^{[2
]}

Huang, M. H. ^{[2
]}

Hu, Y. T. ^{[2
]}

机构：

[1] Natl Tsing Hua Univ, Dept Ind Engn & Engn Management, Hsinchu, Taiwan

[2] Mackay Mem Hosp, Hsinchu, Taiwan

来源：

PROCEEDINGS OF THE 23RD INTERNATIONAL CONFERENCE ON INDUSTRIAL ENGINEERING AND ENGINEERING MANAGEMENT 2016: THEORY AND APPLICATION OF INDUSTRIAL ENGINEERING | 2017年

关键词：

Adverse events; Adverse medication events; Conditional probability; Human factors analysis and classification system (HFACS); ERRORS; DEFINITIONS; FREQUENCY; SYSTEM;

D O I：

10.2991/978-94-6239-255-7_10

中图分类号：

T [工业技术];

学科分类号：

08 ;

摘要：

The study analyzes the adverse events in medication process by HFACS and determines the frequency of AMEs using conditional probability. Four experts were recruited to form a committee for the study: one pharmacist, (working as manager of a pharmacy department), two nurses, and one human factors and ergonomics expert. 17 examples were selected from TPR and 52 causal factors were identified by the committee. The findings show that the traditional approach could underestimate the frequency of AMEs.

引用

页码：51 / 55

页数：5

共 18 条

[1] [Anonymous], 2015, TAIW PAT SAF REP SYS
[2] Medication Error Minimization Scheme (MEMS) in an adult tertiary Intensive Care Unit (ICU) 2009-2011
Breeding, Jeff
Welch, Susie
Whittam, Susan
Buscher, Hergen
Burrows, Fay
Frost, Carmen
Jonkman, Maryke
Mathews, Nicola
Wong, Khai Shin
Wong, Alison
[J]. AUSTRALIAN CRITICAL CARE, 2013, 26 (02) : 58 - 75
[3] NATIONAL STUDY ON THE FREQUENCY, TYPES, CAUSES, AND CONSEQUENCES OF VOLUNTARILY REPORTED EMERGENCY DEPARTMENT MEDICATION ERRORS
Cuong, Julius
Story, Julie L.
Hicks, Rodney W.
Shore, Andrew D.
Morlock, Laura L.
Cheung, Dickson S.
Kelen, Gabor D.
Pronovost, Peter J.
[J]. JOURNAL OF EMERGENCY MEDICINE, 2011, 40 (05) : 485 - 492
[4] An investigation of air accidents in Nigeria using the Human Factors Analysis and Classification System (HFACS) framework
Daramola, Adebukola Yewande
[J]. JOURNAL OF AIR TRANSPORT MANAGEMENT, 2014, 35 : 39 - 50
[5] Clarification of terminology in medication errors - Definitions and classification
Ferner, Robin E.
Aronson, Jeffrey K.
[J]. DRUG SAFETY, 2006, 29 (11) : 1011 - 1022
[6] Comprehensive analysis of a medication dosing error related to CPOE
Horsky, J
Kuperman, GJ
Patel, VL
[J]. JOURNAL OF THE AMERICAN MEDICAL INFORMATICS ASSOCIATION, 2005, 12 (04) : 377 - 382
[7] A COMPARISON OF MEDICATION ERRORS UNDER UNIVERSITY-OF-KENTUCKY UNIT DOSE SYSTEM AND TRADITIONAL DRUG DISTRIBUTION SYSTEMS IN 4 HOSPITALS
HYNNIMAN, CE
CONRAD, WF
URCH, WA
RUDNICK, BR
PARKER, PF
[J]. AMERICAN JOURNAL OF HOSPITAL PHARMACY, 1970, 27 (10): : 802 - &
[8] Medication errors and adverse drug events in pediatric inpatients
Kaushal, R
Bates, DW
Landrigan, C
McKenna, DJ
Clapp, MD
Federico, F
Goldmann, DA
[J]. JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, 2001, 285 (16): : 2114 - 2120
[9] An investigation on unintended reactor trip events in terms of human error hazards of Korean nuclear power plants
Kim, Sa Kil
Lee, Yong Hee
Jang, Tong Il
Oh, Yeon Ju
Shin, Kwang Hyeon
[J]. ANNALS OF NUCLEAR ENERGY, 2014, 65 : 223 - 231
[10] THE NATURE OF ADVERSE EVENTS IN HOSPITALIZED-PATIENTS - RESULTS OF THE HARVARD MEDICAL-PRACTICE STUDY-II
LEAPE, LL
BRENNAN, TA
LAIRD, N
LAWTHERS, AG
LOCALIO, AR
BARNES, BA
HEBERT, L
NEWHOUSE, JP
WEILER, PC
HIATT, H
[J]. NEW ENGLAND JOURNAL OF MEDICINE, 1991, 324 (06) : 377 - 384

← 1 2 →