Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Manchester Academic Health Sciences Centre (MAHSC), University of Manchester, Manchester, United Kingdom.
NIHR Greater Manchester Patient Safety Translational Research Centre, MAHSC, University of Manchester, Manchester, United Kingdom.
PLoS One. 2018 Oct 26;13(10):e0206233. doi: 10.1371/journal.pone.0206233. eCollection 2018.
Medication administration errors (MAEs) are a common risk to patient safety in mental health hospitals, but an absence of in-depth studies to understand the underlying causes of these errors limits the development of effective remedial interventions. This study aimed to investigate the causes of MAEs affecting inpatients in a mental health National Health Service (NHS) hospital in the North West of England.
Registered and student mental health nurses working in inpatient psychiatric units were identified using a combination of direct advertisement and incident reports and invited to participate in semi-structured interviews utilising the critical incident technique. Interviews were designed to capture the participants' experiences of inpatient MAEs. All interviews were transcribed verbatim and subject to framework analysis to illuminate the underlying active failures, error/violation-provoking conditions and latent failures according to Reason's model of accident causation.
A total of 20 participants described 26 MAEs (including 5 near misses) during the interviews. The majority of MAEs were skill-based slips and lapses (n = 16) or mistakes (n = 5), and were caused by a variety of interconnecting error/violation-provoking conditions relating to the patient, medicines used, medicines administration task, health care team, individual nurse and working environment. Some of these local conditions had origins in wider organisational latent failures. Recurrent and influential themes included inadequate staffing levels, unbalanced staff skill mix, interruptions/distractions, concerns with how the medicines administration task was approached and problems with communication.
To our knowledge this is the first published in-depth qualitative study to investigate the underlying causes of specific MAEs in a mental health hospital. Our findings revealed that MAEs may arise due to multiple interacting error and violation provoking conditions and latent 'system' failures, which emphasises the complexity of this everyday task facing practitioners in clinical practice. Future research should focus on developing and testing interventions which address key local and wider organisational 'systems' failures to reduce error.
药物管理失误（MAE）是精神卫生医院患者安全的常见风险，但缺乏深入研究来了解这些失误的根本原因，限制了有效补救干预措施的发展。本研究旨在调查影响英格兰西北部一家国家卫生服务（NHS）精神卫生医院住院患者 MAE 的原因。
使用直接广告和事件报告相结合的方式确定在住院精神病病房工作的注册和学生精神科护士，并邀请他们参加使用关键事件技术的半结构式访谈。访谈旨在捕捉参与者对住院 MAE 的经验。所有访谈均逐字记录，并根据 Reason 的事故因果模型进行框架分析，以阐明潜在故障下的主动故障、错误/违规诱发条件和潜在故障。
共有 20 名参与者在访谈中描述了 26 起 MAE（包括 5 起未遂事件）。大多数 MAE 是技能型失误和失误（n = 16）或错误（n = 5），是由与患者、使用的药物、药物管理任务、医疗保健团队、个体护士和工作环境相关的各种相互关联的错误/违规诱发条件引起的。其中一些局部条件起源于更广泛的组织潜在故障。反复出现且有影响力的主题包括人员配备水平不足、人员技能组合不平衡、中断/分心、对药物管理任务处理方式的关注以及沟通问题。
据我们所知，这是第一项发表的深入定性研究，旨在调查精神卫生医院特定 MAE 的根本原因。我们的研究结果表明，MAE 可能是由于多个相互作用的错误和违规诱发条件以及潜在的“系统”故障引起的，这强调了日常任务的复杂性，这是临床实践中从业人员面临的挑战。未来的研究应集中于开发和测试针对关键本地和更广泛组织“系统”故障的干预措施，以减少错误。
