Department of Patient Safety Örebro University Hospital Örebro Sweden.
School of Health Sciences Faculty of Medicine and Health Örebro University Örebro Sweden.
Nurs Open. 2020 May 31;7(5):1526-1535. doi: 10.1002/nop2.534. eCollection 2020 Sep.
To examine (a) when medication incidents occur and which type is most frequent; (b) consequences for patients; (c) incident reporters' perceptions of causes; and (d) professional categories reporting the incidents.
A descriptive multicentre register study.
This study included 775 medication incident reports from 19 Swedish hospitals during 2016-2017. From the 775 reports, 128 were chosen to establish the third aim. Incidents were classified and analysed statistically. Perceived causes of incidents were analysed using content analysis.
Incidents occurred as often in prescribing as in administering. Wrong dose was the most common error, followed by missed dose and lack of prescription. Most incidents did not harm the patients. Errors in administering reached the patients more often than errors in prescribing. The most frequently perceived causes were shortcomings in knowledge, skills and abilities, followed by workload. Most medication incidents were reported by nurses.
考察(a)用药差错发生的时间和最常见的类型;(b)对患者的后果;(c)差错报告者对原因的看法;以及(d)报告事件的专业类别。
描述性多中心登记研究。
本研究纳入了 2016 年至 2017 年期间来自瑞典 19 家医院的 775 份用药差错报告。在这 775 份报告中,选择了 128 份来建立第三个目的。对差错进行分类并进行统计学分析。使用内容分析法分析了对事件的感知原因。
在医嘱和给药过程中发生差错的频率相同。错误的剂量是最常见的错误,其次是漏用和未开具处方。大多数事件没有对患者造成伤害。给药错误比医嘱错误更常发生在患者身上。最常被感知到的原因是知识、技能和能力不足,其次是工作量过大。大多数用药差错是由护士报告的。