Force Mary VanOyen, Deering Linda, Hubbe John, Andersen Marcy, Hagemann Barbara, Cooper-Hahn Michelle, Peters William
Delnor-Community Hospital, Geneva, Ill 60134, USA.
J Nurs Adm. 2006 Jan;36(1):34-41. doi: 10.1097/00005110-200601000-00009.
A major concern for patient safety in hospitals is accurate medication administration. To improve the medication administration process, nurses and pharmacists must report system problems. Although staff supported the concept of medication error reporting, they did not report errors. Inherent fear of retribution, punitive actions, and professional humiliation prevented self-reporting of medication errors. Our hospital's quality improvement department developed, implemented, and evaluated a program called LifeSavers. Its purpose was to build a nonpunitive culture and to increase medication error reporting by staff. In one year, the LifeSavers program increased medication error disclosures from 14 to 72 reports per month. The successful development of a nonblame culture of medication error reporting led to identified sources of problems and improvement of the medication administration system.
医院患者安全的一个主要关注点是准确给药。为改进给药流程，护士和药剂师必须报告系统问题。尽管工作人员支持用药错误报告的理念，但他们并未报告错误。对报复、惩罚性行动和职业羞辱的内在恐惧阻碍了用药错误的自我报告。我们医院的质量改进部门开发、实施并评估了一个名为“生命救助者”的项目。其目的是建立一种非惩罚性文化，并增加工作人员对用药错误的报告。在一年的时间里，“生命救助者”项目将每月用药错误披露报告从14份增加到72份。用药错误报告非指责文化的成功发展促成了问题根源的查明以及给药系统的改进。
