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巴西医院静脉用药管理中的差错

Errors in the administration of intravenous medication in Brazilian hospitals.

作者信息

Anselmi Maria Luiza, Peduzzi Marina, Dos Santos Claudia Benedita

机构信息

University of São Paulo at Ribeirão Preto College of Nursing, WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil.

出版信息

J Clin Nurs. 2007 Oct;16(10):1839-47. doi: 10.1111/j.1365-2702.2007.01834.x.

Abstract

AIM

To verify the frequency of errors in the preparation and administration of intravenous medication in three Brazilian hospitals in the State of Bahia.

BACKGROUND

The administration of intravenous medications constitutes a central activity in Brazilian nursing. Errors in performing this activity may result in irreparable damage to patients and may compromise the quality of care.

DESIGN

Cross-sectional study, conducted in three hospitals in the State of Bahia, Brazil.

METHODS

Direct observation of the nursing staff (nurse technicians, auxiliary nurses and nurse attendants), preparing and administering intravenous medication.

RESULTS

When preparing medication, wrong patient error did not occur in any of the three hospitals, whereas omission dose was the most frequent error in all study sites. When administering medication, the most frequent errors in the three hospitals were wrong dose and omission dose.

CONCLUSIONS

The rates of error found are considered low compared with similar studies. The most frequent types of errors were wrong dose and omission dose. The hospitals studied showed different results with the smallest rates of errors occurring in hospital 1 that presented the best working conditions. Relevance to clinical practice. Studies such as this one have the potential to improve the quality of care.

摘要

目的

验证巴西巴伊亚州三家医院静脉用药配制与给药过程中的差错发生率。

背景

静脉用药给药是巴西护理工作的核心内容。此项工作中的差错可能给患者造成无法挽回的损害,并可能影响护理质量。

设计

在巴西巴伊亚州的三家医院开展的横断面研究。

方法

直接观察护理人员(护士技术员、助理护士和护理员)配制和给药静脉用药的过程。

结果

在配制药物时,三家医院均未发生患者错误,但漏服剂量是所有研究地点最常见的差错。在给药时,三家医院最常见的差错是剂量错误和漏服剂量。

结论

与类似研究相比,本研究发现的差错率较低。最常见的差错类型是剂量错误和漏服剂量。所研究的医院呈现出不同的结果,1号医院差错率最低,其工作条件最佳。与临床实践的相关性。此类研究有提高护理质量的潜力。

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