229起护士给药错误分析及对策

Analysis of medication administering errors caused by nurses based on 229 cases and preventive strategies

目的分析护士给药错误发生的原因和特点,探讨如何避免发生给药错误。方法在建立半结构性非惩罚护理意外事件上报系统的基础上,回顾分析某三级综合性医院2008～2010年系统上报的229起给药错误事件,对护士发生给药缺陷的类型、特点、原因进行分析。结果①遗漏和"5R"类错误是护士给药错误的主要类别。给药错误的前三位原因为不遵守操作流程(低年资护士)、沟通不良和干扰(高年资护士)。②护士年资是影响给药错误的重要因素,工作年限低于3年的护士给药错误发生率最高,3年以上者发生率明显降低。③护士给药错误容易发生在白天交接班时,尤其是在12∶00左右。④与其他科室相比,外科护士给药错误的发生率更高。⑤给药错误各影响因素中,与结局相关者为沟通(P=0.044)、遗漏(P=0.019)、给药速度(P=0.008)、监测(P=0.000)和药品(P=0.009),Ⅱ级以上结局主要与高危药物有关。结论护理管理人员应根据护士发生给药错误的特点制订针对性的预防措施。护士排班时应增加中午值班人员数量。对重点科室和高危药物应重点监测并提出降低给药错误的风险预案。

Objective To analyze the causes and characteristics of medication administering errors caused by nurses,and to explore preventive strategies. Methods The type,characteristics and causes of 229 cases of medication administering errors were retrospectively analyzed based on the records of the non-punitive adverse events reporting system in a first class hospital from 2008 to 2010. Results Omission and ＂five Rights＂ mistakes were the main types of medication administering errors, The first three causes were violation of checking procedures,poor communication and distractions. Years of working experiencewas an important factor influencing medication administering errors.The incidence of medication administering errors in nurses working fewer than 3 years ranked the highest （35.2percent）. Medication administering errors were more likely to occur during the handover in day shift,especially around 12：00 pro. Compared with other departments,the incidence of medication administering errors was higher in surgical department. Factors influencing the outcomes of medication administering errors were communication （P=0.044） ,omission （P=O.019） ,delivery speed （P=0.008） ,monitoring （P=0.000） and types of drug （P=0.009）. High-alert medications were associated with more severe outcomes. Conclusion Nursing administrators should take different preventive strategies according to the characteristics of medication administering errors caused by nurses,such as increasing the number of nurses at noon,monitoring medication administering in high-risk departments and high-risk drugs.