药物安全事件报告：组织压力时期导致安全事件的因素。
Medication Safety Event Reporting: Factors That Contribute to Safety Events During Times of Organizational Stress.
机构信息
Departments of Surgery (Dr Cohen), Medicine and Emergency Medicine (Dr Berdahl), Nursing (Dr Coleman), Patient Safety (Dr Seferian), Internal Medicine (Mr Henreid and Dr Nuckols), and Pharmacy (Dr Leang), Cedars-Sinai Medical Center, Los Angeles, California.
出版信息
J Nurs Care Qual. 2024;39(1):51-57. doi: 10.1097/NCQ.0000000000000720. Epub 2023 May 9.
BACKGROUND
Incident reports submitted during times of organizational stress may reveal unique insights.
PURPOSE
To understand the insights conveyed in hospital incident reports about how work system factors affected medication safety during a coronavirus disease-2019 (COVID-19) surge.
METHODS
We randomly selected 100 medication safety incident reports from an academic medical center (December 2020 to January 2021), identified near misses and errors, and classified contributing work system factors using the Human Factors Analysis and Classification System-Healthcare.
RESULTS
Among 35 near misses/errors, incident reports described contributing factors (mean 1.3/report) involving skill-based errors (n = 20), communication (n = 8), and tools/technology (n = 4). Reporters linked 7 events to COVID-19.
CONCLUSIONS
Skill-based errors were the most common contributing factors for medication safety events during a COVID-19 surge. Reporters rarely deemed events to be related to COVID-19, despite the tremendous strain of the surge on nurses. Future efforts to improve the utility of incident reports should emphasize the importance of describing work system factors.
背景
在组织压力时期提交的事件报告可能揭示独特的见解。
目的
了解医院事件报告中传达的关于工作系统因素如何在 2019 年冠状病毒病（COVID-19）激增期间影响药物安全的见解。
方法
我们从一所学术医疗中心随机选择了 100 份药物安全事件报告（2020 年 12 月至 2021 年 1 月），识别了接近失误和错误，并使用人因分析和分类系统-医疗保健对促成工作系统的因素进行了分类。
结果
在 35 个接近失误/错误中，事件报告描述了促成因素（每份报告平均 1.3 个），涉及技能错误（n = 20）、沟通（n = 8）和工具/技术（n = 4）。报告员将 7 起事件与 COVID-19 联系起来。
结论
在 COVID-19 激增期间，技能错误是药物安全事件的最常见促成因素。尽管 COVID-19 对护士造成了巨大压力，但报告员很少认为事件与 COVID-19 有关。未来改进事件报告实用性的努力应强调描述工作系统因素的重要性。
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