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报告还是不报告:一项探索 ICU 护士对错误和错误报告看法的描述性研究。

To report or not to report: a descriptive study exploring ICU nurses' perceptions of error and error reporting.

机构信息

Daphne Cockwell School of Nursing, Ryerson University, 350 Victoria Street, Toronto, Ontario, Canada.

出版信息

Intensive Crit Care Nurs. 2010 Feb;26(1):1-9. doi: 10.1016/j.iccn.2009.10.002. Epub 2009 Nov 27.

Abstract

OBJECTIVE

To explore the emergent factors influencing nurses' error reporting preferences, scenarios were developed to probe reporting situations in the intensive care unit.

SETTING

Three Canadian intensive care unit settings including: one urban academic tertiary hospital, one community hospital and one academic paediatric hospital.

RESEARCH METHODOLOGY/DESIGN: Using qualitative descriptive methodology, semi-structured interviews were guided by a script which included a series of both closed and open-ended questions. One near miss and four error scenarios were used as prompts during the interview. Four of the five scenarios were identical across all the three sites; however, one scenario differed in the community site to reflect the distinct practice environment.

MAIN OUTCOME MEASURES

Three key points of analysis included: nurses' error perception, decision to report the scenario and style of reporting (formal and/or informal).

RESULTS

At least 81% of the 37 participants stated that they would report the events in the respective scenarios. Deviations from standards of practice emerged as the primary rationale for participants' perception of error.

CONCLUSION

Nurses working in the intensive care unit readily perceive and are willing to report errors or near misses; however they may choose informal or formal methods to report.

摘要

目的

探索影响护士错误报告偏好的紧急因素,为此开发了场景以探究重症监护病房中的报告情况。

背景

三个加拿大重症监护病房环境,包括:一个城市学术型三级医院、一个社区医院和一个学术型儿科医院。

研究方法/设计:采用定性描述方法,半结构化访谈以脚本为指导,其中包括一系列封闭式和开放式问题。一个接近失误和四个错误场景被用作访谈中的提示。所有三个地点都有四个相同的场景;然而,在社区地点,有一个场景有所不同,以反映不同的实践环境。

主要结果测量

三个分析要点包括:护士对错误的感知、报告场景的决定以及报告风格(正式和/或非正式)。

结果

37 名参与者中至少有 81%表示他们将报告各自场景中的事件。偏离实践标准成为参与者感知错误的主要理由。

结论

在重症监护病房工作的护士很容易感知到错误或接近失误,并愿意报告;然而,他们可能会选择非正式或正式的方法来报告。

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