摘要
目的:描述NICU护士自愿上报用药接近失误的特征,对相关系统因素进行风险识别与分析。方法:采用美国药物安全处方中心的ASSESS-ERRTM用药失误记录单(2006),收集2014年1月至2015年12月北京市4家医院42名NICU护士自愿上报的用药接近失误,应用灰色关联度分析法进行相关原因分析。结果:护士自愿上报134例用药接近失误,以医嘱失误为主(58.2%),风险最高指标是开立医嘱阶段的药物关键信息失误(ξ_2=0.425),通过关联度(r)值对不同用药阶段风险程度进行排序:备药>开立医嘱>配药>给药>监测/教育。结论:通过分析NICU用药接近失误产生的系统风险因素,利于护士有针对性地采取风险管理策略,以提升患儿的用药安全。
Objective： To describe the characteristics and analyze risk factors for medication near-miss errors stemming from the NICU work system based on self-incident reports from staff nurses. Methods： Data on medication errors were collected from a convenience sample of 42 NICU nurses at four hospitals in Beijing from January 2014 to December 2015. The ASSESS-ERRTM Medication System Work sheet was used to collect the data of possible system risk factors resulting from the near-miss error. Grey Relational Analysis was used to examine the associations between the five medication-use processes and the 10 risk elements. Results： A total of 134 medication near-miss errors were reported by nurses. The order prescribing stage had the most medication near-miss errors （58.2%）. The highest systemic risk factor was critical drug information missing （ff2=0.425）, and the rank of risky stage was： repackaging prescribing dispensing administering monitoring/education. Conclusion： Analyzing the possible system risk factors resulting from the near-miss error could be a useful method for nurses to generate hierarchical risk-control strategies and improve medication safety for neonates.
出处
《中国护理管理》
CSCD
2017年第8期1087-1091,共5页
Chinese Nursing Management
关键词
用药接近失误
风险因素
灰色关联度分析法
新生儿重症
medication near-miss error
risk factors
Grey Relational Analysis
severe disease in neonate
