Björkstén Karin Sparring, Bergqvist Monica, Andersén-Karlsson Eva, Benson Lina, Ulfvarson Johanna
Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden.
Psychiatry South Stockhholm, Administration och Ledning, Box 5040, SE-121 05, Johanneshov, Sweden.
BMC Health Serv Res. 2016 Aug 24;16(1):431. doi: 10.1186/s12913-016-1695-9.
Many studies address the prevalence of medication errors but few address medication errors serious enough to be regarded as malpractice. Other studies have analyzed the individual and system contributory factor leading to a medication error. Nurses have a key role in medication administration, and there are contradictory reports on the nurses' work experience in relation to the risk and type for medication errors.
All medication errors where a nurse was held responsible for malpractice (n = 585) during 11 years in Sweden were included. A qualitative content analysis and classification according to the type and the individual and system contributory factors was made. In order to test for possible differences between nurses' work experience and associations within and between the errors and contributory factors, Fisher's exact test was used, and Cohen's kappa (k) was performed to estimate the magnitude and direction of the associations.
There were a total of 613 medication errors in the 585 cases, the most common being "Wrong dose" (41 %), "Wrong patient" (13 %) and "Omission of drug" (12 %). In 95 % of the cases, an average of 1.4 individual contributory factors was found; the most common being "Negligence, forgetfulness or lack of attentiveness" (68 %), "Proper protocol not followed" (25 %), "Lack of knowledge" (13 %) and "Practice beyond scope" (12 %). In 78 % of the cases, an average of 1.7 system contributory factors was found; the most common being "Role overload" (36 %), "Unclear communication or orders" (30 %) and "Lack of adequate access to guidelines or unclear organisational routines" (30 %). The errors "Wrong patient due to mix-up of patients" and "Wrong route" and the contributory factors "Lack of knowledge" and "Negligence, forgetfulness or lack of attentiveness" were more common in less experienced nurses. The experienced nurses were more prone to "Practice beyond scope of practice" and to make errors in spite of "Lack of adequate access to guidelines or unclear organisational routines".
Medication errors regarded as malpractice in Sweden were of the same character as medication errors worldwide. A complex interplay between individual and system factors often contributed to the errors.
许多研究关注用药错误的发生率，但很少有研究涉及严重到可被视为医疗事故的用药错误。其他研究分析了导致用药错误的个人和系统促成因素。护士在给药过程中起着关键作用，关于护士与用药错误风险及类型相关的工作经历，存在相互矛盾的报道。
纳入瑞典11年间所有护士被认定需承担医疗事故责任的用药错误案例（n = 585）。根据类型以及个人和系统促成因素进行定性内容分析和分类。为检验护士工作经历之间以及错误与促成因素之间可能存在的差异，采用了Fisher精确检验，并进行Cohen's kappa（k）分析以估计关联的程度和方向。
585个案例中共有613起用药错误，最常见的是“剂量错误”（41%）、“患者错误”（13%）和“漏服药物”（12%）。在95%的案例中，平均发现1.4个个人促成因素；最常见的是“疏忽、遗忘或注意力不集中”（68%）、“未遵循正确规程”（25%）、“知识缺乏”（13%）和“超出执业范围操作”（12%）。在78%的案例中，平均发现1.7个系统促成因素；最常见的是“角色过载”（36%）、“沟通或医嘱不清晰”（30%）和“缺乏获取指南的充分途径或组织常规不明确”（30%）。“因患者混淆导致患者错误”和“给药途径错误”以及促成因素“知识缺乏”和“疏忽、遗忘或注意力不集中”在经验不足的护士中更为常见。经验丰富的护士更倾向于“超出执业范围操作”，并且尽管“缺乏获取指南有效途径或组织常规不明确”仍会犯错。
在瑞典被视为医疗事故的用药错误与全球范围内的用药错误性质相同。个人和系统因素之间复杂的相互作用往往导致了这些错误。
