Wolf Zane Robinson, Hicks Rodney W, Altmiller Geralyn, Bicknell Patricia
School of Nursing and Health Sciences, La Salle University, 1900 West Olney Avenue, Philadelphia, PA 19141, USA.
Nurse Educ Today. 2009 Aug;29(6):681-8. doi: 10.1016/j.nedt.2009.02.010. Epub 2009 Apr 1.
This retrospective case study examined reports (N=27) of medication errors made by nursing students involving tubing and catheter misconnections. Characteristics of misconnection errors included attributes of events recorded on MEDMARX error reports of the United States Pharmacopeia. Two near miss errors or Category B errors (medication error occurred, did not reach patient) were identified, with 21 Category C medication errors (occurred, with no resulting patient harm), and four Category D errors (need for increased patient monitoring, no patient harm) reported. Reported intravenous tubing errors were more frequent than other type of tubing errors and problems with clamps were present in 12 error reports. Registered nurses discovered most of the errors; some were implicated in the mistakes along with the students.
这项回顾性案例研究调查了护理专业学生发生的涉及输液管和导管误连的用药错误报告(N = 27份)。误连错误的特征包括美国药典MEDMARX错误报告中记录的事件属性。识别出两起险些发生的错误或B类错误(发生了用药错误,但未影响到患者),报告了21起C类用药错误(发生了错误,但未对患者造成伤害),以及4起D类错误(需要加强对患者的监测,未对患者造成伤害)。报告的静脉输液管错误比其他类型的输液管错误更常见,12份错误报告中存在夹子问题。大多数错误是由注册护士发现的;有些错误是学生和护士共同造成的。