给药错误事件根因类型信息指标的确定与电子上报系统设计
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摘要
目的确定给药错误事件电子上报系统的根因类型信息项,以实现事件根因类型分析的结构化、自动化。方法参考根因分析理论框架,研究小组初步拟定给药错误事件根因类型信息项并形成函询问卷,以德尔菲法确定给药错误事件根因类型结构化信息内容,由软件工程师根据上报表模块设计需求,开发给药错误事件根因分析结构化电子上报系统。结果给药错误事件电子上报表根因类型结构化信息内容有激发问题(一级指标)18项,提示答案(二级指标)84项;开发的电子上报系统有上报模块和报表模块,报表模块有查询和分析功能。结论确定的根因类型信息涵盖了质量管理的主要因素,上报系统能帮助护理管理者快速、有效地查寻给药错误事件的根本原因,并根据高发原因采取针对性管理措施,提高管理效率及效能。
Objective To determine root causes in medication errors and to integrate them into electronic adverse safety event reporting system,thus to achieve automatic and structured analysis of root causes in medication errors.Methods Using root cause analysis,the research team summarized root causes of medication errors and developed consultation questionnaire,then conducted a tworound expert consultation using the Delphi process to determine the information items of root causes.At last,software engineers designed a structured module to report root causes of medication errors in electronic adverse safety event reporting system.Results The root cause module included 18 evoked questions and 84 cue answers.The electronic reporting system contained reporting and chart modules which had query and analysis function.Conclusion The root causes cover main factors in quality management of medication error.The reporting system helps managers fastly and effectively understand root causes in medication errors,thus to take targeted measures and enhance work efficiency and efficacy.
Objective To determine root causes in medication errors and to integrate them into electronic adverse safety event reporting system,thus to achieve automatic and structured analysis of root causes in medication errors.Methods Using root cause analysis,the research team summarized root causes of medication errors and developed consultation questionnaire,then conducted a tworound expert consultation using the Delphi process to determine the information items of root causes.At last,software engineers designed a structured module to report root causes of medication errors in electronic adverse safety event reporting system.Results The root cause module included 18 evoked questions and 84 cue answers.The electronic reporting system contained reporting and chart modules which had query and analysis function.Conclusion The root causes cover main factors in quality management of medication error.The reporting system helps managers fastly and effectively understand root causes in medication errors,thus to take targeted measures and enhance work efficiency and efficacy.
引文
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[3]Gong Y,Kang H,Wu X,et al.Enhancing patient safety event reporting.A systematic review of system design features[J].Appl Clin Inform,2017,8(3):893-909.
[4]Elliott P,Martin D,Neville D.Electronic clinical safety reporting system:a benefits evaluation[J].JMIR Med Inform,2014,2(1):e12.
[5]冷婧,关欣,王蕾,等.基于因素分析法的三级甲等医院护理不良事件上报系统设计与应用[J].中国护理管理,2015,15(6):705-708.
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[7]National Patient Safety Foundation.Improving root cause analyses and actions toprevent harm[R].Boston:National Patient Safety Foundation,2016.
[8]刘红玲,马秀敏,赵润平,等.基于根本原因分析法的护理不良事件分析表的设计与应用[J].护理实践与研究,2015,12(1):92-93.
[9]钱援芳,徐东娥.根因分析法在住院患者非计划性拔管管理中的应用[J].中华护理杂志,2012,47(11):979-980.
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[12]宋白娟,邱梅英,何美香.临床用药护理差错现状的调查[J].护理学杂志,2011,26(19):41-44.
[13]Chuang M H,Wang Y F,Chen M,et al.Effectiveness of implementation of a new drug storage label and errorreducing process on the accuracy of drug dispensing[J].JMed Syst,2012,36(3):1469-1474.
[14]Trbovich P,Prakash V,Stewart J,et al.Interruptions during the delivery of high-risk medications[J].J Nurs Adm,2010,40(5):211-218.
[15]付京,程秀华,王侣珍.临床给药护理风险管理的研究现状[J].护理学杂志,2013,28(7):95-97.
[16]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.
[17]Mohr J J,Batalden P B.Improving safety on the front lines:the role of clinical microsystems[J].Qual Saf Health Care,2002,11(1):45-50.
[18]Turkoski B B.Improving patient safety by improving medication communication[J].Orthop Nurs,2009,28(3):150-152.
[19]Manias E,Cranswick N,Newall F,et al.Medication error trends and effects of person-related,environment-related and communication-related factors on medication errors in a paediatric hospital[J].J Paediatr Child Health,2018.doi:10.1111/jpc.14193.
[20]Hung C C,Chu T P,Lee B O,et al.Nurses′attitude and intention of medication administration error reporting[J].J Clin Nurs,2016,25(3-4):445-453.
[21]谢建飞.安全文化培训对提高二级医院护理管理者安全文化感知的效果研究[D].长沙:中南大学,2014.
[22]Rutledge D N,Retrosi T,Ostrowski G.Barriers to medication error reporting among hospital nurses[J].J Clin Nurs,2018,27(9-10):1941-1949.
[23]史婷奇,陈湘玉,陆胜美,等.护理安全事件信息化管理系统的设计与应用[J].护理学杂志,2012,27(21):6-8.
[2]Borland S.Shocking toll of NHS drug errors:up to 22,000deaths a year caused by medication mistakes and dose blunders[EB/OL].(2018-02-23)[2018-08-05].https://www.dailymail.co.uk/health/article-5424789/Up-22-000-deathsyear-caused-medication-mistakes.html?ico=amp-comments-addcomment.
[3]Gong Y,Kang H,Wu X,et al.Enhancing patient safety event reporting.A systematic review of system design features[J].Appl Clin Inform,2017,8(3):893-909.
[4]Elliott P,Martin D,Neville D.Electronic clinical safety reporting system:a benefits evaluation[J].JMIR Med Inform,2014,2(1):e12.
[5]冷婧,关欣,王蕾,等.基于因素分析法的三级甲等医院护理不良事件上报系统设计与应用[J].中国护理管理,2015,15(6):705-708.
[6]The Joint Commission.Framework for conducting a root cause analysis and action plan[EB/OL].(2017-10-11)[2018-08-05].https://www.jointcommission.org/framework_for_conducting_a_root_cause_analysis_and_action_plan/.
[7]National Patient Safety Foundation.Improving root cause analyses and actions toprevent harm[R].Boston:National Patient Safety Foundation,2016.
[8]刘红玲,马秀敏,赵润平,等.基于根本原因分析法的护理不良事件分析表的设计与应用[J].护理实践与研究,2015,12(1):92-93.
[9]钱援芳,徐东娥.根因分析法在住院患者非计划性拔管管理中的应用[J].中华护理杂志,2012,47(11):979-980.
[10]Mills P D,Neily J,Kinney L M,et al.Effective interventions and implementation strategies to reduce adverse drug events in the Veterans Affairs(VA)system[J].Qual Saf Health Care,2008,17(1):37-46.
[11]Ramadaniati H U,Hughes J D,Lee Y P,et al.Simulated medication errors:a means of evaluating healthcare professionals′knowledge and understanding of medication safety[J].Int J Risk Saf Med,2018,29(3-4):149-158.
[12]宋白娟,邱梅英,何美香.临床用药护理差错现状的调查[J].护理学杂志,2011,26(19):41-44.
[13]Chuang M H,Wang Y F,Chen M,et al.Effectiveness of implementation of a new drug storage label and errorreducing process on the accuracy of drug dispensing[J].JMed Syst,2012,36(3):1469-1474.
[14]Trbovich P,Prakash V,Stewart J,et al.Interruptions during the delivery of high-risk medications[J].J Nurs Adm,2010,40(5):211-218.
[15]付京,程秀华,王侣珍.临床给药护理风险管理的研究现状[J].护理学杂志,2013,28(7):95-97.
[16]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.
[17]Mohr J J,Batalden P B.Improving safety on the front lines:the role of clinical microsystems[J].Qual Saf Health Care,2002,11(1):45-50.
[18]Turkoski B B.Improving patient safety by improving medication communication[J].Orthop Nurs,2009,28(3):150-152.
[19]Manias E,Cranswick N,Newall F,et al.Medication error trends and effects of person-related,environment-related and communication-related factors on medication errors in a paediatric hospital[J].J Paediatr Child Health,2018.doi:10.1111/jpc.14193.
[20]Hung C C,Chu T P,Lee B O,et al.Nurses′attitude and intention of medication administration error reporting[J].J Clin Nurs,2016,25(3-4):445-453.
[21]谢建飞.安全文化培训对提高二级医院护理管理者安全文化感知的效果研究[D].长沙:中南大学,2014.
[22]Rutledge D N,Retrosi T,Ostrowski G.Barriers to medication error reporting among hospital nurses[J].J Clin Nurs,2018,27(9-10):1941-1949.
[23]史婷奇,陈湘玉,陆胜美,等.护理安全事件信息化管理系统的设计与应用[J].护理学杂志,2012,27(21):6-8.