Henneman Elizabeth A, Blank Fidela S J, Gawlinski Anna, Henneman Philip L
Amherst School of Nursing, University of Massachusetts, Amherst, MA 01003, USA.
Appl Nurs Res. 2006 May;19(2):70-7. doi: 10.1016/j.apnr.2005.05.006.
The purpose of this study was to gain insight into how nurses recover medical errors in the emergency department (ED) setting.
The research method was of exploratory descriptive design with qualitative analysis. Subjects who signed the informed consent participated in one of four focus groups centering on nurse's role in recovering errors. Questions were asked during the focus groups to elicit information regarding nurse's role in the three phases of error recovery, namely, identifying, interrupting, and correcting the error.
Five themes emerged to describe methods used by nurses to identify errors in the ED setting. These themes included: surveillance, anticipation, double checking, awareness of the "big picture," and experiential "knowing." Five themes emerged as methods used to interrupt errors: patient advocacy, offer of assistance, clarification, verbal interruption, and creation of delay. The themes for correcting an error were assembling the team and involving leadership.
The results of this study provide preliminary evidence of the strategies used by ED nurses in the recovery of medical error. Further research is needed to generalize these findings to other ED settings. Knowledge of effective recovery strategies can ultimately be used to develop interventions for reducing medical error and improving patient safety.
本研究旨在深入了解护士在急诊科环境中如何发现医疗差错。
研究方法为采用定性分析的探索性描述性设计。签署知情同意书的受试者参加了四个以护士在发现差错中的作用为中心的焦点小组之一。在焦点小组中提出问题，以获取有关护士在差错发现的三个阶段（即识别、中断和纠正差错）中的作用的信息。
出现了五个主题来描述护士在急诊科环境中识别差错所采用的方法。这些主题包括：监测、预判、复查、全局意识和经验性“知晓”。出现了五个主题作为中断差错的方法：患者维权、提供协助、澄清、口头中断和制造延误。纠正差错的主题是组建团队和让领导层参与。
本研究结果为急诊科护士发现医疗差错所采用的策略提供了初步证据。需要进一步研究以将这些发现推广到其他急诊科环境。有效发现策略的知识最终可用于制定减少医疗差错和提高患者安全的干预措施。
