Tubing misconnections--a systems failure with human factors: lessons for nursing practice.
作者信息
Simmons Debora, Graves Krisanne
机构信息
Texas A&M Health Science Center, Rural Community Health Institute, College Station, TX, USA.
出版信息
Urol Nurs. 2008 Dec;28(6):460-4.
PMID:19241785
Abstract
In a neonatal unit, an experienced nurse inadvertently connected a feeding tube to an intravenous catheter. An analysis of this error, including the historical perspective, reveals that this threat to safety has been documented since 1972. Implications for nursing practice include the redesign of systems to accommodate human factors science and a change in health care's view of vigilance.
摘要
Zotero 插件