GESTIÓN EN SALUD PÚBLICA: AHRQ Patient Safety Network ► Impact of a reengineered electronic error-reporting system on medication event reporting and care process improvements at an urban medical center.

miércoles, 3 de septiembre de 2014

AHRQ Patient Safety Network ► Impact of a reengineered electronic error-reporting system on medication event reporting and care process improvements at an urban medical center.

Reengineering the medication error reporting system in a hospital can lead to improved reporting of errors, particularly near misses.Jt Comm J Qual Patient Saf. 2014;40;9:398-407.

Impact of a reengineered electronic error-reporting system on medication event reporting and care process improvements at an urban medical center.

McKaig D, Collins C, Elsaid KA. Jt Comm J Qual Patient Saf. 2014;40;9:398-407.

Hospital incident reporting systems are ubiquitous, but many events remain unreported. This pre-post study sought to determine the impact of a reengineered medication error reporting approach. Researchers implemented a Web-based electronic medication error reporting system in concert with a novel work process in which clinical managers perform the first review of the report. The intervention led to increased error reporting, with the majority of errors being near-misses. This finding suggests that under-reporting of medication errors via standard incident reporting mechanisms can be addressed using human factors engineering approaches, which apply to and enhance both the error reporting tool and clinicians' workflow. A past AHRQ WebM&Mperspective discusses how human factors engineering can be used to uncover problems with device design and work processes.

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