文档介绍：给药错误的安全指南案例2ifEBespPracticeEvidenceBasedPractceInformatonSheetsforHealhPratesslo防给药错StrategiestoreducemedicationerrorswithreferencetoolderadultinformatonsourcecottoGaoadpaeaaraopecwaersceaAseCe,arabacita误caseateTheHwa指kcetfawned南tateratacatnariamnudtaceacostaeasa,aetius统计数字惊人根据美国医学研究院2006年7月《预防用药错误》报告,在美国,每年受到用药错误危害的人数达到了150万人,造成的额外医药费损失超过了35亿美元。说得再具体一点,相当于每个住院患者每天都可能遭遇到一次用药错误46%的用药错误发生在入院、出院或改变患者临床状态或转运时医生的新医嘱上。对于基本上可预防的问题,这一统计数字无疑是惊人的由于药品名称或外观相似使用缩写以及小数点后的零,字迹非常潦草患者的历史信息不完整特殊药品的信息不足或过时的警示说明给药错误类型Table1:Typesofmedicationerorsingeneralmedicalpractic每100件意外事件TypeofincidentRate/100incidents用药不当处方错误Inappropriatemedication30给错药物Prescribingeror22剂量错误Administrationerror18副作用Inappropriatedose15过敏反应Sideeffect13分发错误Allergicreaction剂量过大IsIngerror10机体不适Overdose药物潴留SysteminadequaciesMedicationomittedorwithheld6Table2:municationbetwee是eathprofessionals医患间沟通不畅他人行为影响Errordfjudgemet判断错误医务人员间沟通不畅Patentcorsitedcthermedcaoficer病人寻求其他医生Failuretorecognisesonsandsymplo没能辨认出症状和体征忽略了病人病史Omissionofchecingprocedure32295530000忽略核对环节医生过于匆忙Patentmisunderstoodtheirproblemandortreatment病人误解病人评估不充分推荐方案o电脑化护理照顾模式●电脑医嘱处理电脑医嘱警示双人核对病人终端系统派药专注●puterisedphysicianorderentry(CPOE)mayreducetheriskofmisreadingmedicationorders.(GradeB)Individualpatientmedicationsupply-Individualpatientmedicationsupplyshouldbeconsideredforusewhereverpossible.(GradeC),pharmacistsshouldbemadeavailablefordoublecheckingmedicationordersandforconsultation.(GradeB)NursingcaremodelsDoublecheckingofmedicationordersbynursespriortoadministrationmayreducethenumberofmedicationerrors(GradeC)Identifyingadedicatednurseformedicationadministrationmayreducethenumberofmedicationerrorsthroughthereductionofdistractions(GradeD)TheuseofaMedicationAdministrationReviewandSafety(mitteemayhaveapositiveeffectonreducingmedicationerrors,likelyduetotheheightenedawarenessofmedicationerrorpreventionandreporting(GradeC)anizationWHOCollaboratingCentreforPatientSafetySolutonsAideMemoireLook-Alike,sound-alikemedicationnamesPatientSafetySo