作者
Lucian L Leape, David W Bates, David J Cullen, Jeffrey Cooper, Harold J Demonaco, Theresa Gallivan, Robert Hallisey, Jeanette Ives, Nan Laird, Glenn Laffel, Roberta Nemeskal, Laura A Petersen, Kathy Porter, Deborah Servi, Brian F Shea, Stephen D Small, Bobbie J Sweitzer, B Taylor Thompson, Martha Vander Vliet, David Bates, Patricia Hojnowski-Diaz, Stephen Petrycki, Michael Cotugno, Heather Patterson, Mairead Hickey, Sharon Kleefield, Ellen Kinneally, Margaret Dempsey Clapp, J Richard Hackman, Amy Edmondson
发表日期
1995/7/5
期刊
Jama
卷号
274
期号
1
页码范围
35-43
出版商
American Medical Association
简介
Objective
—To identify and evaluate the systems failures that underlie errors causing adverse drug events (ADEs) and potential ADEs.
Design
—Systems analysis of events from a prospective cohort study.
Participants
—All admissions to 11 medical and surgical units in two tertiary care hospitals over a 6-month period.
Main Outcome Measures
—Errors, proximal causes, and systems failures.
Methods
—Errors were detected by interviews of those involved. Errors were classified according to proximal cause and underlying systems failure by multidisciplinary teams of physicians, nurses, pharmacists, and systems analysts.
Results
—During this period, 334 errors were detected as the causes of 264 preventable ADEs and potential ADEs. Sixteen major systems failures were identified as the underlying causes of the errors. The most common systems failure was in the dissemination of drug knowledge, particularly to …
引用总数
学术搜索中的文章
LL Leape, DW Bates, DJ Cullen, J Cooper… - Jama, 1995
LL Leape, DW Bates, DJ Cullen - JAMA, 1995