护理给药错误事件156例分析
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摘要
目的分析护理给药错误发生的原因,为患者用药安全管理提供依据。方法回顾性分析长沙市某三级甲等医院2013年至2016年院内不良事件上报系统收集的156例给药错误事件。结果 156例给药错误中,以静脉给药错误最多,占62.8%;护士发生给药对象错误概率最高,占47.4%;其中,94.9%的给药错误未对患者造成伤害。给药错误的主要原因为未严格执行患者查对制度、疏忽粗心和沟通不良。结论护理管理者应鼓励医护人员主动上报所有的给药错误,对给药错误的资料进行分析,根据护士发生给药错误的特点制订针对性的预防措施。
Objective To provide evidence for patient'medication safety management by analyzing the reasons of medication errors.Methods Clinical data of 156 medication errors were analyzed retrospectively.Results Among the 156 medication errors,62.8% occurred in intravenous administration.Wrong patient accounted for 47.4%,in which 94.9% didn't cause any damage on patients.The main causes of medication errors were violation of checking procedures,negligence and poor communication.Conclusion Nursing managers should encourage medical staffs to report medication errors,analyze them,and then take different preventive strategies according to the characteristics of medication errors caused by nurses.
Objective To provide evidence for patient'medication safety management by analyzing the reasons of medication errors.Methods Clinical data of 156 medication errors were analyzed retrospectively.Results Among the 156 medication errors,62.8% occurred in intravenous administration.Wrong patient accounted for 47.4%,in which 94.9% didn't cause any damage on patients.The main causes of medication errors were violation of checking procedures,negligence and poor communication.Conclusion Nursing managers should encourage medical staffs to report medication errors,analyze them,and then take different preventive strategies according to the characteristics of medication errors caused by nurses.
引文
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[6]蒋银芬,杨如美,佟伟军,等.229起护士给药错误分析及对策[J].中华护理杂志,2011,46(1):62-64.
[7]陆秀文,徐红,楼建华.128起给药错误分析[J].中国护理管理,2011,11(2):63-66.
[8]Davidhizar R,Lonser G.Strategies to decrease medication errors[J].Health Care Manag(Frederick),2003,22(3):211-218.
[9]Beyea S C.Distractions and interruptions in the OR:Evidence for practice[J].Aorn J,2007,86(3):465-467.
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[11]Fowler S B,Sohler P,Zarillo D F.Bar-code technology for medication administration:Medication errors and nurse satisfaction[J].Medsurg Nurs,2009,18(2):103-109.
[12]Sheu S J,Wei I L,Chen C H,et al.Using snowball sampling method with nurses to understand medication administration errors[J].J Clin Nurs,2009,18(4):559-569.
[13]杨莘,王祥,邵文利,等.335起护理不良事件分析及对策[J].中华护理杂志,2010,45(2):130-132.
[14]郑惠芳,谢丽萍,董卫红,等.护理给药错误的调查分析及应对策略[J].解放军护理杂志,2012,29(24):59-62.
[15]万文洁,田梅梅,施雁.护士给药错误管理研究现状[J].中国护理管理,2012,12(7):45-48.
[2]Michael.New products help curb injectable med errors[EB/OL].[2007-07-23].https://www.questia.com/magazine/1P3-1321864891/new-products-help-curb-injectable-med-errors.
[3]Maricle K,Whitehead L,Rhodes M.Examining medication errors in a tertiary hospital[J].J Nurs Care Qual,2007,22(1):20-27.
[4]NCC MERP.Taxonomy of medication errors[EB/OL].[2017-09-26].http://www.nccmerp.org/sites/default/files/taxonomy2001-07-31.pdf.
[5]Cornish P L,Knowles S R,Marchesano R,et al.Unintended medication discrepancies at the time of hospital admission[J].Arch Intern Med,2005,165(4):424-429.
[6]蒋银芬,杨如美,佟伟军,等.229起护士给药错误分析及对策[J].中华护理杂志,2011,46(1):62-64.
[7]陆秀文,徐红,楼建华.128起给药错误分析[J].中国护理管理,2011,11(2):63-66.
[8]Davidhizar R,Lonser G.Strategies to decrease medication errors[J].Health Care Manag(Frederick),2003,22(3):211-218.
[9]Beyea S C.Distractions and interruptions in the OR:Evidence for practice[J].Aorn J,2007,86(3):465-467.
[10]Anthony K,Wiencek C,Bauer C,et al.No interruptions please:Impact of a no interruption zone on medication safety in intensive care units[J].Crit Care Nurse,2010,30(3):21-29.
[11]Fowler S B,Sohler P,Zarillo D F.Bar-code technology for medication administration:Medication errors and nurse satisfaction[J].Medsurg Nurs,2009,18(2):103-109.
[12]Sheu S J,Wei I L,Chen C H,et al.Using snowball sampling method with nurses to understand medication administration errors[J].J Clin Nurs,2009,18(4):559-569.
[13]杨莘,王祥,邵文利,等.335起护理不良事件分析及对策[J].中华护理杂志,2010,45(2):130-132.
[14]郑惠芳,谢丽萍,董卫红,等.护理给药错误的调查分析及应对策略[J].解放军护理杂志,2012,29(24):59-62.
[15]万文洁,田梅梅,施雁.护士给药错误管理研究现状[J].中国护理管理,2012,12(7):45-48.