通过使用迷你根本原因分析和行动减少药物错误引起的非哨兵伤害事件。

Ghada Hussain Al Mardawi, Rajkumar Rajendram, Souzan Mohammed Alowesie, Mufareh Alkatheri
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引用次数: 4

摘要

简介:一个完整的根本原因分析(RCA),比如在哨兵事件之后需要进行的分析,是费时、费力且昂贵的。该质量改进项目使用了类似但简短的过程(mini-RCA和行动;mini-RCA2)对药物错误的反应,造成的伤害不那么严重。方法:2018年,使用mini-RCA2对所有因系统故障而造成伤害但非前哨事件的用药错误进行调查。将引入mini-RCA2前后一年报告的类似用药错误发生率进行比较,以确定该干预措施的影响。通过按药物名称(例如,Humate®P)和/或事件类型(例如,患者入院时家庭用药的处方错误-遗漏)在安全报告系统数据库中搜索报告的用药错误,确定类似事件。估计了这种干预的时间和人工成本。结果:采用mini-RCA2对7例用药错误进行了调查。来自11个临床和非临床科室的48多名工作人员参与了39个系统故障的识别,并提出了42项建议,其中22项(52%)得到了实施。这将类似事件的复发报告从35例(0.57%)减少到21例(0.36%)。虽然这0.21%的绝对降幅没有达到统计学意义,但类似伤害事件的复发率从7次(0.11%)减少到0次(p = 0.016)。当mini-RCA2建议被完全实施时,益处是最大的。这将类似事件的复发率从9(0.21%)降低到0 (p = 0.007)。该干预总共需要251小时(平均±SD, 35.9±16.6小时)。相关劳动力成本为沙特阿拉伯里亚尔(SAR) 34,181(8256美元);平均SAR±SD, 4883±1302[平均US $±SD, 2102±561美元])。结论:使用mini-RCA2来审查用药错误提供了一个结构化的过程来管理报告的事件,监测建议的实施情况,并评估实施措施的有效性。使用这种快速过程来调查造成伤害但不是前哨事件的错误,减少了类似用药错误的复发。虽然这种干预所需的时间和成本并非微不足道,但对患者、医疗保健专业人员和组织的累积效益更大。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Reducing Nonsentinel Harm Events due to Medication Errors by Using Mini-Root Cause Analysis and Action.

Introduction: A full root cause analysis (RCA) such as that required following a sentinel event is time-consuming, labor-intensive, and expensive. This quality improvement project used a similar but abbreviated process (mini-RCA and action; mini-RCA2) in response to medication errors that caused less serious harm.

Methods: In 2018, all medication errors that caused harm due to system failures but were not sentinel events were investigated by mini-RCA2. The incidence of similar medication errors reported in the year before and in the year after the introduction of mini-RCA2 was compared to determine the impact of this intervention. Similar events were identified by searching the safety reporting system database for reported medication errors by drug name (e.g., Humate® P) and/or event type (e.g., prescribing error-omission of a patient's home medications on admission to hospital). The time and labor costs of this intervention were estimated.

Results: Seven medication errors were investigated by mini-RCA2. More than 48 members of staff from 11 clinical and nonclinical departments contributed to the identification of 39 system failures and made 42 recommendations, of which 22 (52%) were implemented. This reduced the recurrence of reports of similar events from 35 (0.57%) to 21 (0.36%). Although this 0.21% absolute decrease did not achieve statistical significance, recurrence of similar harm events was reduced from 7 (0.11%) to 0 (p = 0.016). Benefits were greatest when the mini-RCA2 recommendations were fully implemented. This reduced the recurrence of similar events from 9 (0.21%) to 0 (p = 0.007). A total of 251 hours (mean ± SD, 35.9 ± 16.6 hours) were required for this intervention. The associated labor cost was Saudi Arabia Riyal (SAR) 34,181 (US $8256; mean SAR ± SD, 4883 ± 1302 [mean US $ ± SD, $2102 ± $561]).

Conclusion: The use of mini-RCA2 to review medication errors provided a structured process to manage reported events, monitor the implementation of recommendations, and assess the effectiveness of implemented actions. The use of this rapid process to investigate errors that cause harm but are not sentinel events reduced recurrence of similar medication errors. Although the time and cost required for this intervention is not insignificant, the cumulative benefit to patients, healthcare professionals, and the organization are greater.

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