Preventing medication errors in long-term care: Results and evaluation of a large scale web-based error reporting system

被引:59
作者
Pierson, Stephanie
Hansen, Richard
Greene, Sandra
Williams, Charlotte
Akers, Roger
Jonsson, Mattias
Carey, Timothy
机构
[1] Univ N Carolina, Cecil G Sheps Ctr Hlth Serv Res, Chapel Hill, NC 27599 USA
[2] Univ N Carolina, Sch Pharm, Div Pharmaceut Outcomes & Policy, Chapel Hill, NC 27599 USA
来源
QUALITY & SAFETY IN HEALTH CARE | 2007年 / 16卷 / 04期
关键词
D O I
10.1136/qshc.2007.022483
中图分类号
R19 [保健组织与事业(卫生事业管理)];
学科分类号
摘要
Objective: To describe the implementation and evaluation of a web-based medication error reporting system. Design: Evaluation study. Setting: Long-term care. Participants: 25 nursing homes in the US state of North Carolina. Intervention: Detailed information about all medication errors occurring in a facility during a 1 year period was entered into a web-based reporting system. An evaluation survey was conducted to assess usability and the potential for the system to prevent errors. Main outcome measures: Number and specific characteristics of medication errors reported. A survey evaluating ease of use of the system and whether the participants thought it would help improve medication safety. Results: 23 (92%) sites entered 631 error reports for 2731 discrete error instances when weighted by the number of times the errors were repeated. 51 (8%) errors were classified as having a serious patient impact requiring monitoring/ intervention or worse. The most common errors were dose omission (203, 32%), overdose (91, 14%), underdose (43, 7%), wrong patient (38, 6%), wrong product (38, 6%), and wrong strength (38, 6%). Errors most commonly occurred during medication administration (296, 47%) and were attributed to basic human error (402, 48%). Seven drugs were implicated in a third (175, 28%) of all errors: lorazepam, oxycodone, warfarin, furosemide, hydrocodone, insulin and fentanyl. 20 sites (86% of respondents) completed the evaluation survey and participants found the system easy to use and thought it would increase accuracy of reporting and improve patient safety. Conclusions: The web-based medication error reporting system was easy to use, with strong indications that it would be a valuable tool for preventing future errors.
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页码:297 / 302
页数:6
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