据估计,美国每年约130万人因药物治疗造成非故意性损伤,其中2/3可能是由于治疗差错所致。因此,减少损伤很明显需要努力地减少差错。 系统错误(Systems failures)概念作为差错的根本原因还未被临床广泛接受,相反,传统努力在减少差错上只集中于个体和一系列事件上,如利用培训、告诫、规定和许可来改善工作。为明确和评价系统缺乏所致差错引起的药物不良事件(ADE)和潜在 It is estimated that about 1.3 million people in the United States each year cause unintentional injuries due to medical treatment, of which two thirds may be due to treatment errors. Therefore, it is clear that reducing damage requires efforts to reduce errors. The concept of system failures as the root cause of errors has not been widely accepted in the clinic. Instead, traditional efforts have focused on reducing errors to individuals and a range of incidents, such as using training, cautions, rules, and permissions to improve work. In order to clarify and evaluate the adverse drug events (ADEs) and potential