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The Role of Technology in Medication Safety Incidents: Interpretative Analysis of Patient Safety Incidents Data

机译：技术在药物安全事件中的作用：患者安全事件数据的解释性分析

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This is a study of medication safety incidents reported to the NHS in England (UK) associated with the use of digital technology. An interpretative analysis of 888 incidents reports offers insight into uses and features of this technology associated with medication errors and potential patient harm. Electronic medicines management systems (e.g. Computerised Provider Entry Systems -CPOE) are increasingly used worldwide, giving rise to availability of related patient safety data. A number of studies have provided classifications of the types of errors with this technology and contributing factors. Schiff et al [3], for example, queried incidents reported to the United States Pharmacopeia; more than 63 thousands were classed as related to CPOE. Test case scenarios were generated and used to assess vulnerabilities in current systems. CPOEs were found to lack adequate barriers to protect against wrong orders, or their design made data entry error-prone. In Australia, a study of medication incidents in primary care [1] found IT impacted on patient care, including harm or near misses, disrupted clinical workflow, created inefficiencies and user frustration. Although for some incidents risks had always been present, others were more likely to occur with IT, and some were 'unique to IT' [1]. We undertook a sociotechnical analysis of patient safety incidents reported to the National Reporting and Learning System (NRLS) in England and Wales [2] to better understand the role and impact of digital systems on medication safety in the English National Health Service (NHS). The NRLS contains voluntary anonymised reports from all areas of healthcare.
机译：这是对与利用数字技术相关的英格兰（英国）的NHS报告的药物安全事故的研究。对888个事件报告的解释性分析提供了与药物错误和潜在患者伤害相关的这种技术的用途和功能的洞察。电子药物管理系统（例如计算机化提供商入境系统-CPOE）越来越多地使用全球，从而产生相关患者安全数据的可用性。许多研究提供了这种技术和贡献因素的错误类型。例如，Schiff等[3]，例如，向美国药典报告的疑问事件;超过63,000人被归类为与CPOE相关的。生成测试案例方案并用于评估当前系统中的漏洞。发现CPOES缺乏足够的障碍，以防止错误的订单，或者他们的设计使数据输入错误易受。在澳大利亚，在初级保健中的药物事件研究[1]发现它影响了患者护理，包括伤害或近的未命中，扰乱临床工作流程，产生效率低下和用户挫折。虽然对于一些事件始终存在风险，但其他人更有可能与它发生，有些人是“独特的”[1]。我们对英国国家报告和学习系统（NRLS）进行了对患者安全事件的社会技术分析，并在威尔士[2]以更好地了解数字系统对英国国家卫生服务（NHS）的用药安全的作用和影响。 NRLS包含来自医疗保健所有领域的自愿匿名报告。

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