Misinterpreted Physician’s Prescriptions曲解了医生的处方.pptVIP

Systems Analysis, Causes of Medication Errors, and Error-Prone Abbreviations Learning Objectives Describe the systems factors that play a major role in medication errors Discuss the proximal causes of medication errors Identify error-prone abbreviations and ways to improve communication of ambiguous medication orders Systems, Not People Medication errors are property of the system as a whole rather than results of the acts or omissions by the people in the system Performance improvement requires changing the system, not changing the people Practitioners are sometimes held to an unattainable standard—perfection Perspective Accepting a goal of a 99.9% success rate, we’d have: 2 million documents lost every year by the IRS A major plane crash every 3 days 16,000 items lost every hour in the mail 37,000 errors every hour by automated teller machines 107 erroneous medical procedures performed every day Proximal Causes of Medication Errors Lack of drug knowledge Lack of patient information Rule violations Slips and memory lapses Transcription errors Faulty drug identity checking Faulty interaction with other services Faulty dose checking Infusion pump and parenteral delivery problems Inadequate patient monitoring Drug stocking and delivery problems Preparation errors Lack of standardization Distribution of Medication Errors by Proximal Cause Causes of Errors Based on Key System Elements Lack of information about the patient Lack of information about the drug Communication and teamwork failure Unclear, absent, or look-alike drug labels and packages, and confusing or look-alike or sound-alike drug names Unsafe drug standardization, storage, and distribution Causes of Errors Based on Key System Elements (continued) Nonstandard, flawed, or unsafe medication delivery devices Environmental factors and staffing patterns that do not support safety Inadequate staff orientation, ongoing education, supervision, and competency validation Causes of Errors Based on Key System