Johnson Maree, Young Helen
Centre for Applied Nursing Research, School of Nursing & Midwifery, College of Health & Science, University of Western Sydney, Penrith South DC, New South Wales, Australia.
J Nurs Care Qual. 2011 Apr-Jun;26(2):128-35. doi: 10.1097/NCQ.0b013e3181f54b14.
Medication administration is a frequent nursing activity that is prone to error. In this study of 318 self-reported medication incidents (including near misses), very few resulted in patient harm-7% required intervention or prolonged hospitalization or caused temporary harm. Aronson's classification system provided an excellent framework for analysis of the incidents with a close connection between the type of error and the change strategy to minimize medication incidents. Taking a behavioral approach to medication error classification has provided helpful strategies for nurses such as nurse-call cards on patient lockers when patients are absent and checking of medication sign-off by outgoing and incoming staff at handover.
给药是一项频繁的护理活动,容易出错。在这项对318起自我报告的用药事件(包括险些发生的失误)的研究中,很少有事件导致患者受到伤害——7%的事件需要干预、延长住院时间或造成暂时伤害。阿伦森的分类系统为分析这些事件提供了一个极好的框架,错误类型与减少用药事件的改进策略之间有着密切的联系。采用行为方法对用药错误进行分类为护士提供了有用的策略,例如在患者不在时在患者储物柜上放置呼叫卡,以及在交接班时由交班和接班人员检查用药签字情况。