Tokyo Medical University, Shinjuku-ku, Japan
Tokyo Medical University Hospital, Shinjuku-ku, Japan.
BMJ Open Qual. 2024 Jun 27;13(2):e002809. doi: 10.1136/bmjoq-2024-002809.
Intravenous medication errors continue to significantly impact patient safety and outcomes. This study sought to clarify the complexity and risks of the intravenous administration process.
A qualitative focus group interview study.
Focused interviews were conducted using process mapping with frontline nurses responsible for medication administration in September 2020.
Front line experiened nurses from a Japanese tertiary teaching hospital.
The primary outcome measure was to identify the mental models frontline nurses used during intravenous medication administration, which influence their interactions with patients, and secondarily, to examine the medication process gaps between the mental models nurses perceive and the actual defined medication administration process.
We found gaps between the perceived clinical administration process and the real process challenges with an emphasis on the importance of verifying to see if the drug was ordered for the patient immediately before its administration.
This novel and applied improvement approach can help nurses and managers better understand the process vulnerability of the infusion process and develop a deeper understanding of the administration steps useful for reliably improving the safety of intravenous medications.
静脉用药错误继续对患者安全和结果产生重大影响。本研究旨在阐明静脉给药过程的复杂性和风险。
定性焦点小组访谈研究。
2020 年 9 月,对负责药物管理的一线护士进行了基于流程映射的焦点小组访谈。
来自日本一家三级教学医院的一线有经验护士。
主要结果测量是确定一线护士在静脉用药管理过程中使用的心智模型,这些模型影响他们与患者的互动;其次,检查护士感知的药物治疗过程差距与实际定义的药物管理过程之间的差距。
我们发现感知到的临床管理过程与实际过程之间存在差距,重点强调了在给药前立即核实药物是否为患者开具的重要性。
这种新颖且实用的改进方法可以帮助护士和管理人员更好地了解输液过程的流程脆弱性,并深入了解给药步骤,有助于可靠地提高静脉用药的安全性。