Wakefield D S, Wakefield B J, Uden-Holman T, Blegen M A
Health Sciences Center, University of Iowa Health Sciences Center, Iowa City, USA.
Best Pract Benchmarking Healthc. 1996 Jul-Aug;1(4):191-7.
Assuring that medication administration error (MAE) reports are reliable and valid is of great significance for the patient, the hospital, and the nurse. In most hospitals, MAE reporting relies on the nurse who discovers an error to initiate an error report, whether the error was committed by that nurse or someone else. Because of the potential for negative consequences, there may be significant disincentives for the nurse to report the error. This, the first of two articles, describes the results of a large-scale survey designed to assess nurses' perceptions of the reasons why MAE may not be reported. The companion article compares nurses' estimates of the extent to which MAEs are reported with the actual reported medication error rates.
Nurses in 24 acute-care hospitals were surveyed to determine perceptions of reasons why medication errors may not be reported.
The factor analysis reveals four factors explaining why staff nurses may not report medication errors: fear, disagreement over whether an error occurred, administrative responses to medication errors, and effort required to report MAEs.
There are potential changes in both systems and management responses to MAEs that could improve current practice. These changes need to take into account the influences of organizational, professional, and work group culture.
确保用药差错（MAE）报告的可靠性和有效性对患者、医院及护士而言意义重大。在大多数医院，用药差错报告依赖于发现差错的护士来发起差错报告，无论该差错是由该护士还是其他人所犯。由于可能产生负面后果，护士报告差错可能会面临重大阻碍。本文是系列两篇文章中的第一篇，描述了一项大规模调查的结果，该调查旨在评估护士对用药差错未被报告原因的看法。配套文章将护士对用药差错报告程度的估计与实际报告的用药差错率进行了比较。
对24家急症护理医院的护士进行了调查，以确定对用药差错未被报告原因的看法。
因子分析揭示了四个解释注册护士可能不报告用药差错的因素：恐惧、对是否发生差错存在分歧、对用药差错的管理反应以及报告用药差错所需的努力。
用药差错的系统和管理反应方面存在潜在变化，可改善当前做法。这些变化需要考虑组织、专业和工作群体文化的影响。
