查错奖励法对输液区查对制度落实的效果研究

The effectiveness of error-finding and incentive mothod in carrying out regulations for double-checking in the infusion area

目的 将安全文化理论与激励理论相结合,在门诊输液区采取＂查错奖励法＂,建立奖励机制与错误自动登记机制,达到查对制度真正落实.方法 用＂查错奖励法＂取代传统的＂责备与羞耻＂的文化,即缺陷扣分逞罚法.将输液流程分为接待电脑排序-配药-注射三个环节,每一环节护士查对上一环节的错误,同时尽量让本环节不出错误,让错误充分暴露、并能及时纠正、阻止错误演变成差错甚至事故,并从自动登记的错误中分析改进系统,再有错误再分析再改进,直至错误逐渐减少.结果 发现4390处错误,但演变成差错造成对病人的伤害为0.结论 在输液区将安全文化理论与激励理论有机结合,能使查对制度得到更好的落实,病人得到安全的治疗.

Objective To establish the system for rewards and self-recorded errors by taking error-finding and incentive method in the clinic infusion area. Methods Error-finding and incentive method was used to replace traditional ＂b lame and shame＂ culture, namely defect points punishment method.The infusion process was divided into three links - infusion prescription, medication preparation, and injection. Each link was checked by the nurses to prevent or correct errors. The system was improved from self-recorded errors until the errors were gradually reduced. Results 4390 errors were found but none of them became a medical accidence. Conclusions The combination of safety culture with incentive theory in the infusion area can make the regulations for ouble-checking carry out smoothly and patients are treated more safely.