Carlton Gaya, Blegen Mary A
School of Nursing, University of Colorado at Denver and Health Sciences, USA.
Annu Rev Nurs Res. 2006;24:19-38.
Patient safety has become a major concern for both society and policymakers. Since nurses are intimately involved in the delivery of medications and are ultimately responsible during the medication administration phase, it is important for nursing to understand factors contributing to medication administration errors. The purpose of this chapter is to identify the incidence of these errors and the associated factors in an attempt to better understand the problem and lessen future error occurrence. Literature review revealed both active failures and latent conditions established in Reason's theory remain prevalent in current literature where active failures often display themselves in the form of incorrect drug calculations, lack of individual knowledge, and failure to follow established protocol. Latent conditions are evidenced as time pressures, fatigue, understaffing, inexperience, design deficiencies, and inadequate equipment and may lie dormant within a system until combined with active failures to create opportunity for error. Although medication error research has shifted in emphasis toward identification of system problems inherent in error occurrence, no one force emerges as a clear antecedent, reinforcing the need for further research and replication of existing studies with emphasis placed on more dependable reporting measures through which nurses are not threatened by reprisal.
患者安全已成为社会和政策制定者主要关注的问题。由于护士密切参与药物的发放过程,并且在给药阶段承担最终责任,因此护理人员了解导致给药错误的因素非常重要。本章的目的是确定这些错误的发生率和相关因素,以便更好地理解该问题并减少未来错误的发生。文献综述显示,瑞森理论中所阐述的主动失误和潜在条件在当前文献中仍然普遍存在,其中主动失误通常表现为错误的药物计算、个人知识不足以及未遵循既定规程。潜在条件表现为时间压力、疲劳、人员配备不足、经验不足、设计缺陷以及设备不足,这些因素可能在系统中潜伏,直到与主动失误相结合,从而为错误创造机会。尽管药物错误研究的重点已转向识别错误发生所固有的系统问题,但没有一种因素能明确成为先行因素,这进一步凸显了开展更多研究以及重复现有研究的必要性,重点是采用更可靠的报告措施,使护士不会因报复而受到威胁。