purpose of this study was to determine the percentage of self-reported intraoperative medication errors that could be prevented by CDS algorithms. METHODS: In this retrospective cross-sectional study, we obtained safety reports involving medication errors documented by anesthesia clinicians between August 2020 and August 2022 at a 1046-bed tertiary care academic medical center. Reviewers classified each medication error by its stage in the medication use process, error type, presence of an adverse medication event, and its associated severity and preventability by CDS. Informational gaps were corroborated by retrospective chart review and disagreements between reviewers were resolved by consensus. The primary outcome was the percentage of errors that were preventable by CDS. Secondary outcomes were preventability by CDS stratified by medication error type and severity. RESULTS: We received 127 safety reports involving 80 medication errors, and 76/80 (95%) of the errors were classified as preventable by CDS. Certain error types were more likely to be preventable by CDS than others (P < .001). The most likely error types to be preventable by CDS were wrong medication (N = 36, 100% rated as preventable), wrong dose (N = 30, 100% rated as preventable), and documentation errors (N = 3, 100% rated as preventable). The least likely error type to be preventable by CDS was inadvertent bolus (N = 3, none rated as preventable). CONCLUSIONS: Ninety-five percent of self-reported medication errors in the operating room were classified as preventable by CDS. Future research should include a randomized controlled trial to assess medication error rates and types with and without the use of CDS....

中文翻译：

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临床决策支持作为手术室用药错误的预防工具：一项回顾性横断面研究


本研究的目的是确定 CDS 算法可以预防的自我报告的术中用药错误的百分比。方法：在这项回顾性横断面研究中，我们获得了麻醉临床医生在 2020 年 8 月至 2022 年 8 月期间在一家拥有 1046 个床位的三级护理学术医疗中心记录的涉及用药错误的安全报告。审核人员根据药物使用过程中的阶段、错误类型、不良药物事件的存在及其相关严重性和 CDS 的可预防性对每个药物错误进行分类。信息差距通过回顾性图表审查得到证实，审查者之间的分歧通过协商一致解决。主要结果是 CDS 可预防的错误百分比。次要结果是 CDS 的可预防性，按用药错误类型和严重程度分层。结果：我们收到 127 份安全报告，涉及 80 起用药错误，其中 76/80 (95%) 的错误被归类为 CDS 可预防的错误。某些错误类型比其他错误类型更有可能被 CDS 预防 (P < .001)。 CDS 最有可能预防的错误类型是错误用药（N = 36，100% 被评为可预防）、错误剂量（N = 30，100% 被评为可预防）和记录错误（N = 3，100% 被评为可预防）作为可以预防的）。 CDS 最不可能预防的错误类型是无意推注（N = 3，没有一个被评为可预防）。结论：手术室中 95% 的自我报告用药错误被归类为可通过 CDS 预防。未来的研究应包括一项随机对照试验，以评估使用和不使用 CDS 的用药错误率和类型……