Stevens Kathleen R, Engh Eileen P, Tubbs-Cooley Heather, Conley Deborah Marks, Cupit Tammy, D'Errico Ellen, DiNapoli Pam, Fischer Joleen Lynn, Freed Ruth, Kotzer Anne Marie, Lindgren Carolyn L, Marino Marie Ann, Mestas Lisa, Perdue Jessica, Powers Rebekah, Radovich Patricia, Rice Karen, Riley Linda P, Rosenfeld Peri, Roussel Linda, Ryan-Wenger Nancy A, Searle-Leach Linda, Shonka Nicole M, Smith Vicki L, Sweatt Laura, Townsend-Gervis Mary, Wathen Ellen, Withycombe Janice S
Professor and Director, Improvement Science Research Network, MC 7949, University of Texas Health Science Center San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229-3900.
Nursing Research and Development Programs Manager, Children's National Health System, Washington, DC.
Res Nurs Health. 2017 Jun;40(3):197-205. doi: 10.1002/nur.21791. Epub 2017 Mar 15.
Frontline nurses encounter operational failures (OFs), or breakdowns in system processes, that hinder care, erode quality, and threaten patient safety. Previous research has relied on external observers to identify OFs; nurses have been passive participants in the identification of system failures that impede their ability to deliver safe and effective care. To better understand frontline nurses' direct experiences with OFs in hospitals, we conducted a multi-site study within a national research network to describe the rate and categories of OFs detected by nurses as they provided direct patient care. Data were collected by 774 nurses working in 67 adult and pediatric medical-surgical units in 23 hospitals. Nurses systematically recorded data about OFs encountered during 10 work shifts over a 20-day period. In total, nurses reported 27,298 OFs over 4,497 shifts, a rate of 6.07 OFs per shift. The highest rate of failures occurred in the category of Equipment/Supplies, and the lowest rate occurred in the category of Physical Unit/Layout. No differences in OF rate were detected based on hospital size, teaching status, or unit type. Given the scale of this study, we conclude that OFs are frequent and varied across system processes, and that organizations may readily obtain crucial information about OFs from frontline nurses. Nurses' detection of OFs could provide organizations with rich, real-time information about system operations to improve organizational reliability. © 2017 Wiley Periodicals, Inc.
一线护士会遇到操作失误（OFs），即系统流程出现故障，这会妨碍护理工作、降低护理质量并威胁患者安全。以往的研究依赖外部观察者来识别操作失误；护士在识别妨碍其提供安全有效护理能力的系统故障方面一直是被动参与者。为了更好地了解一线护士在医院中与操作失误的直接经历，我们在一个全国性研究网络内进行了一项多地点研究，以描述护士在提供直接患者护理时检测到的操作失误的发生率和类别。数据由在23家医院的67个成人及儿科内科和外科病房工作的774名护士收集。护士们系统地记录了在20天内10个工作日班次中遇到的操作失误的数据。在总共4497个班次中，护士们报告了27298次操作失误，每班失误率为6.07次。失误率最高的类别是设备/用品，最低的类别是物理单元/布局。根据医院规模、教学状况或病房类型，未检测到操作失误率的差异。鉴于本研究的规模，我们得出结论，操作失误在系统流程中频繁且多样，组织可以很容易地从一线护士那里获得有关操作失误的关键信息。护士对操作失误的检测可以为组织提供有关系统运行的丰富实时信息，以提高组织的可靠性。© 2017威利期刊公司
