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学生在给药阶段发生用药错误的特征:一项描述性研究。

Characteristics of medication errors made by students during the administration phase: a descriptive study.

作者信息

Wolf Zane Robinson, Hicks Rodney, Serembus Joanne Farley

机构信息

La Salle University School of Nursing, Philadelphia, PA 19141, USA.

出版信息

J Prof Nurs. 2006 Jan-Feb;22(1):39-51. doi: 10.1016/j.profnurs.2005.12.008.

Abstract

Faculty concentrate on teaching nursing students about safe medication administration practices and on challenging them to develop skills for calculating drug dose and intravenous flow rate problems. In spite of these efforts, students make medication errors and little is known about the attributes of these errors. Therefore, this descriptive, retrospective, secondary analysis study examined the characteristics of medication errors made by nursing students during the administration phase of the medication use process as reported to the MEDMARX, a database operated by the United States Pharmacopeia through the Patient Safety Program. Fewer than 3% of 1,305 student-made medication errors occurring in the administration process resulted in patient harm. Most were omission errors, followed by errors of giving the wrong dose (amount) of a drug. The most prevalent cause of the errors was students' performance deficits, whereas inexperience and distractions were leading contributing factors. The antimicrobial therapeutic class of drugs and the 10 subcategories within this class were the most commonly reported medications involved. Insulin was the highest-frequency single medication reported. Overall, this study shows that students' administration errors may be more frequent than suspected. Faculty might consider curriculum revisions that incorporate medication use safety throughout each course in nursing major courses.

摘要

教师专注于教导护理专业学生安全用药的实践,并促使他们培养计算药物剂量和静脉输液流速问题的技能。尽管付出了这些努力,学生仍会出现用药错误,而对于这些错误的特点却知之甚少。因此,这项描述性、回顾性的二次分析研究,考察了护理专业学生在用药过程给药阶段所犯用药错误的特征,这些错误是上报给MEDMARX的,MEDMARX是美国药典通过患者安全计划运营的一个数据库。在给药过程中发生的1305起学生用药错误中,不到3%导致了患者伤害。大多数是漏服错误,其次是给药剂量错误。错误最普遍的原因是学生的操作缺陷,而缺乏经验和注意力分散是主要促成因素。抗菌治疗类药物及其该类别中的10个子类别是报告中涉及最常见的药物。胰岛素是报告频率最高的单一药物。总体而言,这项研究表明,学生的给药错误可能比预想的更频繁。教师可能会考虑修订课程,将用药安全纳入护理专业主要课程的每一门课程中。

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