Hicks Rodney W, Becker Shawn C
United States Pharmacopeia, Center for the Advancement of Patient Safety, Rockville, MD 20852-1790, USA.
J Infus Nurs. 2006 Jan-Feb;29(1):20-7. doi: 10.1097/00129804-200601000-00005.
Medication errors can be harmful, especially if they involve the intravenous (IV) route of administration. A mixed-methodology study using a 5-year review of 73,769 IV-related medication errors from a national medication error reporting program indicates that between 3% and 5% of these errors were harmful. The leading type of error was omission, and the leading cause of error involved clinician performance deficit. Using content analysis, three themes-product shortage, calculation errors, and tubing interconnectivity-emerge and appear to predispose patients to harm. Nurses often participate in IV therapy, and these findings have implications for practice and patient safety. Voluntary medication error-reporting programs afford an opportunity to improve patient care and to further understanding about the nature of IV-related medication errors.
用药错误可能有害,尤其是涉及静脉注射(IV)给药途径时。一项混合方法研究对国家用药错误报告项目中73769例与静脉注射相关的用药错误进行了为期5年的回顾,结果表明其中3%至5%的错误是有害的。主要的错误类型是遗漏,主要的错误原因是临床医生操作失误。通过内容分析,出现了三个主题——药品短缺、计算错误和输液管连接性——似乎使患者更容易受到伤害。护士经常参与静脉治疗,这些发现对实践和患者安全具有启示意义。自愿性用药错误报告项目为改善患者护理以及进一步了解与静脉注射相关的用药错误的性质提供了契机。