You Mi-Ae, Choe Mi-Hyeon, Park Geun-Ok, Kim Sang-Hee, Son Youn-Jung
College of Nursing, Ajou University, Suwon, South Korea.
Soonchunhyang University Hospital, Cheonan, South Korea.
Int J Qual Health Care. 2015 Aug;27(4):276-83. doi: 10.1093/intqhc/mzv036. Epub 2015 Jun 7.
To identify reasons for medication administration errors (MAEs) and why they are unreported, and estimate the percentage of MAEs actually reported among hospital nurses.
A cross-sectional survey design.
Three university hospitals in three South Korean provinces.
A total of 312 hospital staff nurses were included in this study.
Medication administration errors.
Actual MAEs were experienced by 217 nurses (69.6%) during their clinical career, whereas 149 nurses (47.8%) perceived that MAEs only occur less than 20% rate. MAEs occurred mostly during intravenous (IV) administrations. Nurses perceived that the most common reasons for MAEs were inadequate number of nurses in each working shift (4.88 ± 1.05) and administering drugs with similar names or labels (4.49 ± 0.94). The most prevalent reasons for unreported MAEs included fears of being blamed (4.36 ± 1.10) and having too much emphasis on MAEs as a measure of nursing care quality (4.32 ± 1.02). The three most frequent errors perceived by nurses for non-IV related MAEs included administering medications to the incorrect patients and incorrect medication doses and drug choices. The three most frequent IV related MAEs included incorrect infusion rates, patients and medication doses.
Nurse-staffing adequacy could be helpful to prevent MAEs among nurses as well ongoing education, and training regarding safe medication administration using the problem-based simulation education. In addition, encouraging nurses to identify and report work related errors in a non-punitive milieu will increase error reporting.
确定用药错误(MAEs)的原因及其未报告的原因,并估计医院护士中实际报告的MAEs的百分比。
横断面调查设计。
韩国三个省份的三所大学医院。
本研究共纳入312名医院注册护士。
用药错误。
217名护士(69.6%)在其临床职业生涯中经历过实际的MAEs,而149名护士(47.8%)认为MAEs的发生率仅低于20%。MAEs大多发生在静脉注射期间。护士们认为MAEs最常见的原因是每个工作班次的护士数量不足(4.88±1.05)以及使用名称或标签相似的药物(4.49±0.94)。未报告MAEs的最普遍原因包括害怕被指责(4.36±1.10)以及过于强调MAEs作为护理质量的一项衡量指标(4.32±1.02)。护士们认为非静脉注射相关MAEs最常见的三个错误包括给错误的患者用药、用药剂量错误和药物选择错误。与静脉注射相关的MAEs最常见的三个错误包括输液速度错误、患者错误和用药剂量错误。
充足的护士配备以及持续教育和使用基于问题的模拟教育进行安全用药管理培训,可能有助于预防护士中的MAEs。此外,鼓励护士在非惩罚性环境中识别和报告工作相关错误将增加错误报告率。