Report calls for strategies to reduce medication errors
http://www.100md.com
《英国医生杂志》
Comprehensive strategies梤ather than piecemeal efforts梐nd measures that focus on the entire process of medication rather than on individual mistakes are needed to reduce the incidence of serious errors, said a UK report published last week.
The report, Building a safer NHS for patients. Improving medication safety, reviewed the causes and frequency of medication error and identified models of good practice to improve medication safety.
It found that the causes of errors were complex, involving human lapses and mistakes. Attention was usually focused on the actions of individuals who were considered to be the cause of error, the report warned. However, it found that systems weaknesses that predisposed to human error were important and recommended checks and error traps that should be built into all medication processes, including prescribing, dispensing, and drug administration.
In particular, the report called for improved information management and technology. "The NHS has, over many years, failed effectively to deploy information management and technology to handle clinical information, including prescribing processes and drug administration," it stated, recommending the introduction and implementation of well designed information management solutions to reduce the scope for mistakes and lapses in medication.
Key steps proposed by the report for safer prescribing included active management and review of long term repeat prescribing; clear treatment plans shared with all professionals involved in a patient抯 care; and double checking of all complex dose calculations.
Greater use of information technology梚ncluding implementation of electronic care records and effective electronic prescribing systems梬as considered central to reducing the risk of medication error. Efforts to reduce dispensing errors should include formal dispensary checking systems and procedures and checking medicines with patients when they are dispensed.
The report recommended that appropriate training should be provided for all health service staff involved in the handling of medication and the introduction of clear drug administration procedures in all settings where medicines are given. Drugs should be checked by a second person in high risk circumstances, including intravenous infusions and complex calculations.
The report also made practical recommendations for specific groups of patients and drugs that pose particular risk of medication error. These included the development of clear procedures for the documentation of allergies to drugs and the use of electronic prescribing systems with automatic alerts for drug allergies. To reduce medication errors in seriously ill patients, particularly the administration of drugs by the wrong route, oral and intravenous drugs should not be taken to a patient抯 bedside at the same time. Training and assessment of competence in paediatric drug therapy梚ncluding calculations of doses and infusion rates梥hould be introduced to reduce the risk of drug errors in children.
Current guidance and standards on prescribing, dispensing, and administration of medicines are fragmented and divided between a range of professional and NHS regulatory bodies, the report noted. It suggested that "Overarching national standards should be developed linking the various strands of medicines use within the NHS." The National Patient Safety Agency and the National Institute for Clinical Excellence (NICE) have been asked to develop such standards.
The report formed part of government efforts to reduce the number of serious errors in the use of prescribed drugs by 40%, an aim set by the Chief Medical Officer in 2001. The health minister, Lord Norman Warner, said: "Improving quality of care and patient safety has always been at the heart of the government抯 health strategy. A prescribed medicine is the most frequent treatment provided for NHS patients, so ensuring that drug treatment is safe is key."
Building a safer NHS for patients. Improving medication safety is available at www.doh.gov.uk/buildsafenhs/medicationsafety/(London Susan Mayor)
The report, Building a safer NHS for patients. Improving medication safety, reviewed the causes and frequency of medication error and identified models of good practice to improve medication safety.
It found that the causes of errors were complex, involving human lapses and mistakes. Attention was usually focused on the actions of individuals who were considered to be the cause of error, the report warned. However, it found that systems weaknesses that predisposed to human error were important and recommended checks and error traps that should be built into all medication processes, including prescribing, dispensing, and drug administration.
In particular, the report called for improved information management and technology. "The NHS has, over many years, failed effectively to deploy information management and technology to handle clinical information, including prescribing processes and drug administration," it stated, recommending the introduction and implementation of well designed information management solutions to reduce the scope for mistakes and lapses in medication.
Key steps proposed by the report for safer prescribing included active management and review of long term repeat prescribing; clear treatment plans shared with all professionals involved in a patient抯 care; and double checking of all complex dose calculations.
Greater use of information technology梚ncluding implementation of electronic care records and effective electronic prescribing systems梬as considered central to reducing the risk of medication error. Efforts to reduce dispensing errors should include formal dispensary checking systems and procedures and checking medicines with patients when they are dispensed.
The report recommended that appropriate training should be provided for all health service staff involved in the handling of medication and the introduction of clear drug administration procedures in all settings where medicines are given. Drugs should be checked by a second person in high risk circumstances, including intravenous infusions and complex calculations.
The report also made practical recommendations for specific groups of patients and drugs that pose particular risk of medication error. These included the development of clear procedures for the documentation of allergies to drugs and the use of electronic prescribing systems with automatic alerts for drug allergies. To reduce medication errors in seriously ill patients, particularly the administration of drugs by the wrong route, oral and intravenous drugs should not be taken to a patient抯 bedside at the same time. Training and assessment of competence in paediatric drug therapy梚ncluding calculations of doses and infusion rates梥hould be introduced to reduce the risk of drug errors in children.
Current guidance and standards on prescribing, dispensing, and administration of medicines are fragmented and divided between a range of professional and NHS regulatory bodies, the report noted. It suggested that "Overarching national standards should be developed linking the various strands of medicines use within the NHS." The National Patient Safety Agency and the National Institute for Clinical Excellence (NICE) have been asked to develop such standards.
The report formed part of government efforts to reduce the number of serious errors in the use of prescribed drugs by 40%, an aim set by the Chief Medical Officer in 2001. The health minister, Lord Norman Warner, said: "Improving quality of care and patient safety has always been at the heart of the government抯 health strategy. A prescribed medicine is the most frequent treatment provided for NHS patients, so ensuring that drug treatment is safe is key."
Building a safer NHS for patients. Improving medication safety is available at www.doh.gov.uk/buildsafenhs/medicationsafety/(London Susan Mayor)