Learning from prescribing errors

被引:44
作者
Dean, B
机构
[1] Hammersmith Hosp NHS Trust, Pharmacist Clin Serv, London W12 0HS, England
[2] Hammersmith Hosp NHS Trust, Acad Pharm Unit, London W12 0HS, England
来源
QUALITY & SAFETY IN HEALTH CARE | 2002年 / 11卷 / 03期
关键词
D O I
10.1136/qhc.11.3.258
中图分类号
R19 [保健组织与事业(卫生事业管理)];
学科分类号
摘要
The importance of learning from medical error has recently received increasing emphasis. This paper focuses on prescribing errors and argues that, while learning from prescribing errors is a laudable goal, there are currently barriers that can prevent this occurring. Learning from errors can take place on an individual level, at a team level, and across an organisation. Barriers to learning from prescribing errors include the non-discovery of many prescribing errors, lack of feedback to the prescriber when errors are discovered by other healthcare professionals, and a culture that does not encourage reflection on errors together with why they occurred and how they can be prevented. Changes are needed in both systems and culture to provide an environment in which lessons can be learnt from errors and put into practice.
引用
收藏
页码:258 / 260
页数:3
相关论文
共 30 条
[1]  
[Anonymous], BUILD SAF NHS PAT
[2]  
ARNDT M, 1994, J ADV NURS, V19, P519
[3]  
Baker H M, 1997, Image J Nurs Sch, V29, P155, DOI 10.1111/j.1547-5069.1997.tb01549.x
[4]  
Barber N, 1998, CLIN RISK, V4, P103
[5]  
Barker K.N., 1962, AM J HOSP PHARM, V19, P360
[6]   INCIDENCE OF ADVERSE DRUG EVENTS AND POTENTIAL ADVERSE DRUG EVENTS - IMPLICATIONS FOR PREVENTION [J].
BATES, DW ;
CULLEN, DJ ;
LAIRD, N ;
PETERSEN, LA ;
SMALL, SD ;
SERVI, D ;
LAFFEL, G ;
SWEITZER, BJ ;
SHEA, BF ;
HALLISEY, R ;
VANDERVLIET, M ;
NEMESKAL, R ;
LEAPE, LL .
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, 1995, 274 (01) :29-34
[7]  
Bird FE., 1996, Practical loss control leadership
[8]  
Calliari D, 1995, J Contin Educ Nurs, V26, P11
[9]   Validity and reliability of observational methods for studying medication administration errors [J].
Dean, B ;
Barber, N .
AMERICAN JOURNAL OF HEALTH-SYSTEM PHARMACY, 2001, 58 (01) :54-59
[10]   Causes of prescribing errors in hospital inpatients: a prospective study [J].
Dean, B ;
Schachter, M ;
Vincent, C ;
Barber, N .
LANCET, 2002, 359 (9315) :1373-1378