Nursing Department, Chi Mei Medical Center, Yung Kang City, Tainan, Taiwan.
Nurs Outlook. 2010 Jan-Feb;58(1):17-25. doi: 10.1016/j.outlook.2009.06.001.
This study examined factors that were determined to lead to failures in reporting medication administration errors (MAEs) for 838 frontline nurses from 5 teaching hospitals in Taiwan. The underreporting of these errors is a challenge to medication safety improvement. Results showed that 337 (47%) participating nurses had failed to report self- or coworker-MAEs and 376 nurses (52.4%) had not failed to report. The strongest predictors of the failure were experience of making MAEs, differences in attitude toward reporting self- and coworker-MAEs, and perceived MAE reporting rate in current work. The reporting barriers of fear, perception of nursing quality, and perception of nursing professional development significantly contributed to failure to report. Educating nurses about the goals of incident reporting systems and using MAE data to enhance patient safety culture is recommended. Further, hospital administrators should provide information and encouragement to nurses whose responsibility it is to report MAEs.
本研究旨在探讨导致台湾 5 所教学医院 838 名一线护士未能报告用药错误（MAE）的因素。这些错误的漏报对改善用药安全构成挑战。结果显示，337 名（47%）参与护士未能报告自身或同事的 MAE，376 名护士（52.4%）未报告。导致漏报的最强预测因素是发生 MAE 的经验、对报告自身和同事 MAE 的态度差异，以及对当前工作中 MAE 报告率的看法。对护理质量和护理职业发展的看法是导致漏报的重要原因。建议对护士进行关于事件报告系统目标的教育，并利用 MAE 数据加强患者安全文化。此外，医院管理人员应为有责任报告 MAE 的护士提供信息和鼓励。
