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护士用药错误的发生率及影响因素分析:一项回顾性研究

Analysis of the Incidence and Factors Influencing Medication Administration Errors Among Nurses: A Retrospective Study.

作者信息

Li Bingyu, Yue Liqing, Peng Huan, Chen Xiuwen, Sohaib Muhammad, Peng Bin, Zhang Tiange, Zou Weizhen

机构信息

Teaching and Research Section of Clinical Nursing, Xiangya Hospital, Central South University, Changsha, Hunan, China.

Xiangya School of Nursing, Central South University, Changsha, Hunan, China.

出版信息

J Clin Nurs. 2024 Oct 9. doi: 10.1111/jocn.17483.

Abstract

AIMS

To explore the incidence and factors influencing medication administration errors (MAEs) among nurses.

BACKGROUND

Medication administration is a global concern for patient safety. Few studies have assessed the incidence of MAEs or explored factors that considered the interplay between behaviour, the individual and the environment.

METHODS

This retrospective study included 342 MAEs reported in the electronic nursing adverse event reporting system between January 2019 and September 2023 at a university-affiliated teaching hospital in China. Data on nurses' demographics and medication administration were extracted from the nursing adverse event reports. The reports were classified according to the severity of patient harm. The causes of the 342 MAEs were retrospectively analysed using content analysis based on Bandura's social cognitive theory. Descriptive statistics were used to calculate the proportion of medication errors and the distribution of subcategories.

RESULTS

In total, 74.3% of MAEs were adverse events owing to mistakes and resulted in no harm or only minor consequences for patients. Nurses aged 26-35 years and those with 6-10 years of experience were the most common groups experiencing MAEs. Factors influencing MAEs included personal ('knowledge and skills' and 'physical state'), environmental ('equipment and infrastructure,' 'work settings' and 'workload and workflow') and behavioural ('task performance' and 'supervision and communication') factors. The study further highlighted the interrelationships among personal, behavioural and environmental factors.

CONCLUSION

Multiple factors influence MAEs among nurses. Nurse-related MAEs and the relationship between behaviours, individual factors and the environment, as well as ways to reduce the occurrence of MAEs, should be considered in depth.

RELEVANCE TO CLINICAL PRACTICE

Understanding the factors influencing MAEs can inform training programs and improve the clinical judgement of healthcare professionals involved in medication administration, ultimately improving patient prognoses and reducing MAEs.

PATIENT OR PUBLIC CONTRIBUTION

The findings can help develop clinical guidelines for preventing MAEs.

摘要

目的

探讨护士用药错误(MAEs)的发生率及影响因素。

背景

用药安全是全球关注的患者安全问题。很少有研究评估用药错误的发生率或探讨行为、个体和环境之间相互作用的影响因素。

方法

这项回顾性研究纳入了2019年1月至2023年9月在中国一所大学附属医院的电子护理不良事件报告系统中报告的342例用药错误。护士人口统计学和用药数据从护理不良事件报告中提取。报告根据对患者造成伤害的严重程度进行分类。基于班杜拉的社会认知理论,采用内容分析法对342例用药错误的原因进行回顾性分析。描述性统计用于计算用药错误的比例和子类别的分布。

结果

总体而言,74.3%的用药错误是由于失误导致的不良事件,对患者没有造成伤害或仅产生轻微后果。年龄在26 - 35岁以及有6 - 10年工作经验的护士是发生用药错误最常见的群体。影响用药错误的因素包括个人因素(“知识和技能”以及“身体状态”)、环境因素(“设备和基础设施”、“工作环境”以及“工作量和工作流程”)和行为因素(“任务执行”以及“监督和沟通”)。该研究进一步强调了个人、行为和环境因素之间的相互关系。

结论

多种因素影响护士的用药错误。应深入考虑与护士相关的用药错误以及行为、个体因素与环境之间的关系,以及减少用药错误发生的方法。

与临床实践的相关性

了解影响用药错误的因素可为培训项目提供参考,并改善参与用药管理的医护人员的临床判断力,最终改善患者预后并减少用药错误。

患者或公众贡献

研究结果有助于制定预防用药错误的临床指南。

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