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了解大医院中护士在报告接近错误时遗漏的经历。

Understanding nurses' experiences with near-miss error reporting omissions in large hospitals.

机构信息

Department of Nursing, Sehan University, Yeongam-gun, Korea.

出版信息

Nurs Open. 2021 Sep;8(5):2696-2704. doi: 10.1002/nop2.827. Epub 2021 Mar 3.

Abstract

AIM

This qualitative study aimed to provide an in-depth understanding of nurses' experiences with near-miss errors and report omissions known to be direct or indirect causes of medical accidents in hospitals and cited as precursors of serious medical accidents.

DESIGN

This study collected experiences of research participants through an interview as a qualitative research method and confirmed the meaning through an inductive approach.

METHODS

We selected nine nurses with various levels of experience from 27 May to 10 June 2019 for analysis. We adopted phenomenological research methods and procedures proposed by Colaizzi (Existential-phenomenological alternative for psychology, 1978) and established the feasibility and integrity of our results based on narrative studies proposed by Lincoln and Guba (Naturalistic inquiry, 1985).

RESULTS

This study demonstrated that near-miss errors and report omissions experienced by professional nurses could be merged into the following themes: lack of cognitive susceptibility to near-miss errors; confusion about the reporting system for near-miss errors; lack of knowledge about near-miss errors; disappointment with results of reporting near-miss errors; and fear of reporting near-miss errors. These results strongly suggest the need to improve recognition efforts based on a socio-educational viewpoint involving the so-called openness about failures.

摘要

目的

本定性研究旨在深入了解护士在医院中经历的接近失误和报告遗漏的情况,这些失误和遗漏被认为是医疗事故的直接或间接原因,并被认为是严重医疗事故的前兆。

设计

本研究通过访谈收集研究参与者的经验,作为一种定性研究方法,并通过归纳法确认其意义。

方法

我们于 2019 年 5 月 27 日至 6 月 10 日期间,从 27 名护士中选择了 9 名具有不同经验水平的护士进行分析。我们采用了 Colaizzi(1978)提出的现象学研究方法和程序,并根据 Lincoln 和 Guba(1985)提出的叙事研究,确定了我们研究结果的可行性和完整性。

结果

本研究表明,专业护士经历的接近失误和报告遗漏可以合并为以下主题:对接近失误缺乏认知敏感性;对接近失误报告系统的混淆;缺乏对接近失误的了解;对报告接近失误的结果感到失望;以及对报告接近失误的恐惧。这些结果强烈表明,需要基于涉及所谓失败公开性的社会教育观点来加强识别工作。

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