İlaç kaynaklı tıbbi hata / olay bildirimlerin Dünya Sağlık Örgütü “Hasta Güvenliği Uluslararası Sınıflandırması”na göre değerlendirilmesi

Year 2020, Volume: 3 Issue: 1, 20 - 25, 15.01.2020

Yasemin Aslan

https://doi.org/10.32322/jhsm.612510

Cited By: 7

Abstract

Amaç: Sağlık
kurumlarında etkili bir güvenlik kültürü oluşturmanın temel hedeflerinden biri
tıbbi hataların azaltılmasıdır. Dünya genelinde en sık yapılan tıbbi hata
türlerinden biri ilaç hatalarıdır ve bu hatalar hasta güvenliği açısından önemli
bir tehdit oluşturmaktadır. Bu çalışmanın amacı, bir üniversite hastanesindeki
ilaç kaynaklı olay bildirimlerin Dünya Sağlık Örgütü Hasta Güvenliği
Uluslararası Sınıflandırma Sistemi ve zarar derecelerine göre
değerlendirilmesidir.

Gereç ve Yöntem: Araştırmanın evrenini İstanbul Anadolu Yakası’nda yer alan bir üniversite
hastanesinde 01.01.2015-30.06.2017 tarihleri arasında kalite yönetim sistemi
üzerinden elektronik olarak yapılan ilaç kaynaklı olay bildirimler oluşturmaktadır.

Bulgular:
Çalışma bulgularına göre, toplam 369 ilaçla ilgili bildirim yapılmış olup, tüm
bildirimler arasında ilaç kaynaklı olay bildirimlerin oranı %24,67 olarak
bulunmuştur. DSÖ sınıflandırma sistemine göre bu bildirimlerin %27,10’unun
istem/reçeteleme, %20,87’si hazırlık/doz ayarlama, %20,33’ünün izlem, %19,24’ünün
uygulama ve %10,03’ünün depolama aşamalarında meydana geldiği tespit
edilmiştir. Hataların %56,91’inin hastaya zarar vermediği, %24,39’unun hafif
zarar, %18,43’ünün orta dereceli zarar ve %0,27’sinin şiddetli zarar veren
kategoride yer aldığı görülmüştür.

Sonuç: Sonuçlar
değerlendirildiğinde ilaçla ilgili olay bildirimlerin en fazla istem/reçeteleme
ve hazırlık/doz ayarlama aşamalarında meydan geldiği ve hataların büyük bir
kısmının hastaya zarar vermediği belirlenmiştir. Bu kategorilerde yer alan
hatalar hastaya ulaşmayan ramak kala olaylar olduğu için kurum adına
iyileştirme fırsatları yakalamak açısından önemlidir. Alınacak aksiyonlarla uzun
vadede ilaç hatalarının azaltılması mümkündür.

Keywords

İlaç hatası, sınıflandırma, Dünya Sağlık Örgütü

Evaluation of medication related medical errors / events according to the World Health Organization “International Classification for Patient Safety”

Abstract

Aim: The main
objectives of creating an effective safety culture in health institutions is to
reduce medical errors. One of the most common types of medical errors worldwide
is medication errors and these errors are a major threat to patient safety. The
aim of this study is to evaluate medication related events in a university hospital
according to the World Health Organization International Classification for
Patient Safety and degree of harm.

Material and Method: The universe of the research consists of medication related events
notifications made on a quality management system between 01.01.2015 and
30.06.2017 in a university hospital located on the Asian side of Istanbul.

Results: According
to the findings of the study, a total of 369 medication related events were
made, and the rate of medication related events notifications among all reports
was 24.67%. According to the World Health Organization classification system it
was determined to 27.10% of these events are prescribing, 20.87% are
preparation/dispensing, 20.33% monitoring, 19.24% administration and 10.03%
storage. It was found that 56.91% of the errors did not harm the patient,
24.39% of them caused mild harm, 18.43% of them caused moderate harm and 0.27%
of them caused severe harm.

Conclusion: When
the results are evaluated, it is found that medication related events mostly
occurred during the prescribing and preparation/dispensing stages and most of
the errors did not harm the patient. The errors in these categories are
important for finding improvement opportunities on behalf of the institution,
since they are events that do not reach the patient. It is possible to reduce medication
errors in the long term by taking improvement action.

Keywords

Medication error, classification, World Health Organization

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