给药错误事件根因类型信息指标的确定与电子上报系统设计

目的确定给药错误事件电子上报系统的根因类型信息项,以实现事件根因类型分析的结构化、自动化。方法参考根因分析理论框架,研究小组初步拟定给药错误事件根因类型信息项并形成函询问卷,以德尔菲法确定给药错误事件根因类型结构化信息内容,由软件工程师根据上报表模块设计需求,开发给药错误事件根因分析结构化电子上报系统。结果给药错误事件电子上报表根因类型结构化信息内容有激发问题(一级指标)18项,提示答案(二级指标)84项;开发的电子上报系统有上报模块和报表模块,报表模块有查询和分析功能。结论确定的根因类型信息涵盖了质量管理的主要因素,上报系统能帮助护理管理者快速、有效地查寻给药错误事件的根本原因,并根据高发原因采取针对性管理措施,提高管理效率及效能。

Root causes of medication errors and integration in electronic adverse safety event reporting system

Objective To determine root causes in medication errors and to integrate them into electronic adverse safety event reporting system,thus to achieve automatic and structured analysis of root causes in medication errors.Methods Using root cause analysis,the research team summarized root causes of medication errors and developed consultation questionnaire,then conducted a tworound expert consultation using the Delphi process to determine the information items of root causes.At last,software engineers designed a structured module to report root causes of medication errors m electronic adverse safety event reporting system.Results The root cause module included 18 evoked questions and 84 cue answers.The electronic reporting system contained reporting and chart modules which had query and analysis function.Conclusion The root causes cover main factorsin quahty management of medication error.The reporting system helps managers lastly and effectively understand root causes in medication errors,thus to take targeted measures and enhance work efficiency and efficacy.