Working to minimize medication errors and adverse drug events (面) is a worthwhile goal for healthcare practices. 消除所有错误和ade, 然而, 不太可能是因为医疗环境的快节奏, 供应商面临的众多需求, 以及市场上数量惊人的药物.
分析了28个以上的CRICO策略,500起医疗事故索赔显示，九分之一的案件涉及与药物有关的问题. 进一步, the analysis noted that prescribing even one medication involves multiple steps; thus, “当药物治疗过程扩大到体积时, 速度, 以及典型医疗环境的复杂性, 人类的机会, 技术, 系统性错误也会激增.”1 因此, being prepared to handle these situations and learn from them is a priority for creating a culture of safety that is continually evolving and improving.
医疗保健实践不仅应该有适当的流程和程序来指导药物安全, 它们也应该有适当的报告制度和程序, 分析, 寻址, 揭露用药错误, 面, 和未遂事故(在本文中统称为“用药事故”或简称“事故”). 进一步, staff members should have ample opportunities to learn from medication mishaps that occur in the practice and in the healthcare community at large.
报告用药事故
Reporting medication mishaps — within a healthcare practice and to external entities — can provide valuable data for assessing and improving medication safety. 药物错误和ADE报告的强制性要求因州而异. 保密和自愿的错误报告项目——比如食品和药物管理局的 提交确证 以及安全用药实践研究所(ISMP) 用药错误报告程序 -还收集数据和传播有关药物错误原因的信息.
Healthcare practices should have 指导方针s and policies that clearly establish what types of errors and events should be reported, 他们应该如何报告, 应该向谁报告. 此外，应该建立一个功能系统来记录用药事故. 该系统应捕获必要的信息，以充分评估和研究每个事故.
Practice leaders and managers can facilitate these efforts by encouraging staff to report medication mishaps (even if the errors were caught or corrected) and commending staff whose actions bring these issues to light. A nonpunitive approach to medication mishaps will help facilitate the reporting process and reinforce safety as the practice’s top priority.2
分析用药事故
根本原因分析 通常是确定药物事故发生的方式和原因的第一步. The best way to initiate the analysis might be to examine the healthcare practice’s current policies and procedures, 哪些应该清楚地定义评估事故事件的适当行动, 例如，节省材料或用品，可能有助于确定问题的原因.
除了, staff members who are involved in a medication mishap should help review and assess the incident and the circumstances involved. Management should seek their input on strategies for improving system- and/or process-related issues that potentially contributed to the mishap. 就像报告过程一样, the process for 分析 medication mishaps should be nonpunitive and reflect the organization’s commitment to a culture of safety.
健康研究 & 教育信托基金, ISMP, 和医疗集团管理协会也建议, 当试图识别错误及其原因时, healthcare practices might find it helpful to seek external feedback from local pharmacies and hospitals about any possible errors originating in the practice. 这种反馈可以提供有助于改进内部流程的有价值的信息.3
解决用药事故
在分析了用药事故的根本原因之后, designated staff members should recommend and implement any changes or additional steps to the practice’s procedures for prescribing, 管理, 存储, 或者配药. 例如, staff members might recommend (a) tailoring electronic health record (EHR) alerts for certain commonly prescribed or high-risk medications, (b)物理修改药物存储空间，以分离外观相似/声音相似的产品, or (c) further establishing or refining key steps in the medication reconciliation and informed consent processes.
另外, practice leaders should determine a viable way to communicate critical information about medication mishaps with staff, 是否单独(e).g.，在发送到员工邮箱的警报中)或作为一个组(例如.g.，在一次员工会议上). Timely and proactive communication will encourage staff members to participate in medication safety initiatives and feel comfortable making recommendations and asking 问题.
披露用药事故
Perhaps one of the most difficult aspects of managing medication mishaps is disclosing them to the affected patient and, 如果适用的话, 他/她的照顾者. 尽管困难重重, ha说明了ul incidents should be addressed with honesty and transparency as part of a well-defined disclosure process. (注意: 尽管披露相关的医疗信息是以病人为中心的护理的一个重要方面, 医疗保健提供者应该认识到，并非所有情况都可以或应该通过披露来管理. 例如, “侥幸脱险”应该根据具体情况进行管理, disclosure may depend on whether the patient is aware of the situation and whether disclosure can help prevent a recurrence.)
协助资料披露程序, healthcare practices should have policies in place that guide disclosure activities and provide specific strategies for disclosing medication errors and 面, 比如谁会出席, 什么措辞合适?, 以及后续行动将如何进行. 任何披露活动都需要记录在患者的病历中, 而且应该只包括事实信息，而不是推测性信息.
另外, clinicians 工作人员 who are involved in serious medication mishaps should be offered counseling services and emotional support to help address feelings of guilt, 悲伤, 压力, 或愤怒. 通常被称为医疗事故的“第二受害者”, as many as half of all clinicians might be involved in serious adverse events at least once during their careers.4 安全文化不仅鼓励适当的制度和程序, 同时也支持了患者的身心安全, 供应商, 工作人员.
要了解有关披露意外结果的更多信息，请参阅MedPro的相关 检查表, 指导方针, 资源列表. 有关支持第二受害者的更多信息，请参阅标题为“支持第二受害者”的文章 不良患者结果对医疗保健提供者的影响:支持第二受害者.
从用药事故中学习
Learning from medication mishaps that occur in your healthcare practice and in other practices and organizations is one of the best ways to prevent repeat occurrences. 在安全文化中, 所有的不幸都应该被看作是学习的机会, 从事故报告中收集的信息应用于改进药物安全流程.
支持持续学习的环境, 工作人员需要持续的培训，了解药物错误的原因和预防, 还有美高美集团4688新药物的教育, 技术, 和设备. 工作人员也应接受彻底的培训，精通与报告有关的办公室政策和程序, 分析, 寻址, 披露用药事故.
Routine evaluations of a healthcare practice’s care processes and medication safety initiatives will present an opportunity for 供应商 工作人员 to demonstrate competency in safety procedures and strategize how best to develop new initiatives or improve existing protocols.
另外, healthcare practices can use their EHR systems to support efforts to better understand and reduce medication mishaps. 有关更多信息，请参阅MedPro的指南标题 在您的医疗保健实践中使用电子病历系统作为质量改进工具.
总之
当用药错误时, 面, 或者发生未遂事件, 确定“如何”和“为什么”的情况是必要的，以减轻未来的灾难的风险, 改善病人安全, 减少责任风险. 同样重要的是培育一个充分支持有效制度和过程的环境, 鼓励员工参与和遵守, 并促进员工的学习和发展. 安全文化将激励员工从用药事故中吸取教训, 参与寻找解决方案, 并在实践中分享药物安全的责任.
尾注
1 CRICO策略. (2017). 药物相关的医疗事故风险:CRICO 2016 CBS基准报告. 从检索 www.说明了.哈佛大学.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Medication
2 安全用药实践研究所. (2009). 改善社区药房用药安全:评估变革的风险和机会. 从检索 http://ismp.org/communityRx/aroc/
3 卫生研究 & 教育信托基金，安全用药实践研究所，医疗集团管理协会. (2008). 创造用药安全. 患者安全途径.
4 医疗保健研究和质量机构. (2019年9月7日). 第二个受害者:对涉及错误和不良事件的临床医生的支持. AHRQ患者安全网络. 从检索 http://psnet.ahrq.gov /引物/底漆/ 30 / support-for-clinicians-involved-in-errors-and-adverse-events-second-victims #
此处提供的信息和指导不应被解释为医疗或法律建议. 因为适用于你的情况的事实可能会有所不同, 或者适用于您所在司法管辖区的法规可能有所不同, please contact your attorney or other professional advisors if you have any 问题 related to your legal or medical obligations or rights, 州或联邦法律, 合同的解释, 或者其他法律问题.
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