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利用事件报告来预防用药错误。

Using incident reports to inform the prevention of medication administration errors.

作者信息

Härkänen Marja, Saano Susanna, Vehviläinen-Julkunen Katri

机构信息

Department of Nursing Science, University of Eastern Finland, Kuopio, Finland.

Kuopio University Hospital, Kuopio, Finland.

出版信息

J Clin Nurs. 2017 Nov;26(21-22):3486-3499. doi: 10.1111/jocn.13713. Epub 2017 Apr 20.

DOI:10.1111/jocn.13713
PMID:28042673
Abstract

AIMS AND OBJECTIVES

To describe ways of preventing medication administration errors based on reporters' views expressed in medication administration incident reports.

BACKGROUND

Medication administration errors are very common, and nurses play important roles in committing and in preventing such errors. Thus far, incident reporters' perceptions of how to prevent medication administration errors have rarely been analysed.

DESIGN AND METHODS

This is a qualitative, descriptive study using an inductive content analysis of the incident reports related to medication administration errors (n = 1012). These free-text descriptions include reporters' views on preventing the reoccurrence of medication administration errors. The data were collected from two hospitals in Finland and pertain to incidents that were reported between 1 January 2013 and 31 December 2014.

RESULTS

Reporters' views on preventing medication administration errors were divided into three main categories related to individuals (health professionals), teams and organisations. The following categories related to individuals in preventing medication administration errors were identified: (1) accuracy and preciseness; (2) verification; and (3) following the guidelines, responsibility and attitude towards work. The team categories were as follows: (1) distribution of work; (2) flow of information and cooperation; and (3) documenting and marking the drug information. The categories related to organisation were as follows: (1) work environment; (2) resources; (3) training; (4) guidelines; and (5) development of the work.

CONCLUSIONS

Health professionals should administer medication with a high moral awareness and an attempt to concentrate on the task. Nonetheless, the system should support health professionals by providing a reasonable work environment and encouraging collaboration among the providers to facilitate the safe administration of medication.

RELEVANCE TO CLINICAL PRACTICE

Although there are numerous approaches to supporting medication safety, approaches that support the ability of individual health professionals to manage daily medications should be prioritised.

摘要

目的与目标

基于用药差错事件报告中报告者的观点,描述预防用药差错的方法。

背景

用药差错非常普遍,护士在发生和预防此类差错中发挥着重要作用。到目前为止,很少分析事件报告者对如何预防用药差错的看法。

设计与方法

这是一项定性描述性研究,采用归纳性内容分析法对与用药差错相关的事件报告(n = 1012)进行分析。这些自由文本描述包括报告者对预防用药差错再次发生的看法。数据收集自芬兰的两家医院,涉及2013年1月1日至2014年12月31日期间报告的事件。

结果

报告者对预防用药差错的看法分为与个人(卫生专业人员)、团队和组织相关的三大类。确定了以下与个人预防用药差错相关的类别:(1)准确性和精确性;(2)核查;(3)遵循指南、责任和工作态度。团队类别如下:(1)工作分配;(2)信息流通与合作;(3)记录和标记药物信息。与组织相关的类别如下:(1)工作环境;(2)资源;(3)培训;(4)指南;(5)工作改进。

结论

卫生专业人员应以高度的道德意识给药,并努力专注于这项任务。尽管如此,系统应通过提供合理的工作环境并鼓励提供者之间的协作来支持卫生专业人员,以促进安全给药。

与临床实践的相关性

尽管有许多支持用药安全的方法,但应优先考虑支持个体卫生专业人员管理日常用药能力的方法。

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