Pape Tess M, Guerra Denise M, Muzquiz Marguerite, Bryant John B, Ingram Michelle, Schranner Bonnie, Alcala Armando, Sharp Johanna, Bishop Dawn, Carreno Estella, Welker Jesusita
Quality Coordinator, University Health System, San Antonio, Texas, USA.
J Contin Educ Nurs. 2005 May-Jun;36(3):108-16; quiz 141-2. doi: 10.3928/0022-0124-20050501-08.
Contributing factors to medication errors include distractions, lack of focus, and failure to follow standard operating procedures. The nursing unit is vulnerable to a multitude of interruptions and distractions that affect the working memory and the ability to focus during critical times. Methods that prevent these environmental effects on nurses can help avert medication errors.
A process improvement study examined the effects of standard protocols and visible signage within a hospital setting. The project was patterned after another study using similar techniques. Rapid Cycle Testing was used as one of the strategies for this process improvement project. Rapid Cycle Tests have become a part of the newly adopted Define, Measure, Analyze, Improve, and Control steps at this particular hospital.
As a result, a medication administration check-list improved focus and standardized practice. Visible signage also reduced nurses' distractions and improved focus.
The results provide evidence that protocol checklists and signage can be used as reminders to reduce distractions, and are simple, inexpensive tools for medication safety.
用药错误的促成因素包括分心、注意力不集中以及未遵循标准操作程序。护理单元容易受到多种干扰,这些干扰会影响工作记忆以及关键时刻的专注能力。防止这些对护士的环境影响的方法有助于避免用药错误。
一项流程改进研究考察了医院环境中标准规程和可见标识的效果。该项目仿照另一项使用类似技术的研究开展。快速循环测试被用作此流程改进项目的策略之一。快速循环测试已成为这家特定医院新采用的定义、测量、分析、改进和控制步骤的一部分。
结果,一份用药管理检查表提高了注意力并使操作标准化。可见标识也减少了护士的分心并提高了注意力。
结果证明,规程检查表和标识可用作减少分心的提醒物,是保障用药安全的简单且低成本的工具。