信息化给药闭环管理模式对护理给药不良事件的影响  

Influence of information drug close-loop management mode on adverse events of nursing medication

作　　者：陈付红[1] 陈亚丹[2] 吕丽敏[3] 马蕾[1] Chen Fuhong;Chen Yadan;Lyu Limin;Ma Lei(Nursing Department,the First Affiliated Hospital of Xiamen University,Xiamen 361003,China;Department of Cardiac Surgery,the First Affiliated Hospital of Xiamen University,Xiamen 361003,China;Newborn Room,the First Affiliated Hospital of Xiamen University,Xiamen 361003,China)

机构地区：[1]厦门大学附属第一医院护理部,厦门361003 [2]厦门大学附属第一医院心脏外科,厦门361003 [3]厦门大学附属第一医院新生儿室,厦门361003

出　　处：《中华现代护理杂志》2020年第10期1372-1375,共4页Chinese Journal of Modern Nursing

摘　　要：目的调查信息化给药闭环管理模式对护理给药不良事件的影响,并对实施信息化给药闭环管理模式后的46例护理给药不良事件进行分析,了解事件发生的特点,并制订对策,以减少护理给药错误的发生。方法回顾性分析厦门大学附属第一医院实施信息化给药闭环管理后(2018年1—12月)系统上报的46起护理给药不良事件,对46起事件从差错的类别、原因、环节等方面进行分析,并将各类事件与信息化给药闭环系统实施前的2017年全年发生的护理给药不良事件进行比较。结果实施给药闭环管理后,各类给药不良事件与2017年比较有所降低,但差异无统计学意义(P>0.05),其中身份识别错误17起(17/46,36.96%),给药遗漏8起(8/46,17.39%),剂量和途径错误分别7起(7/46,15.22%)和5起(5/46,10.87%)。发生给药差错的环节主要为给药环节(26起)和摆药环节(14起)。结论给药不良事件最常发生在给药环节,而身份错误是最常见的错误类型,护理管理者应针对护理给药错误的种类及特点制订针对性的预防措施,持续监控并提高给药闭环扫码率,加强护士培训,做好给药及摆药时的查对。Objective To explore the effects of information drug close-loop management mode on adverse events of nursing medication and to analyze the 46 cases of adverse events after implementing the information drug close-loop management mode so as to understand the event characteristics and formulate the countermeasures with the aim to reduce the nursing medication errors.Methods We retrospectively analyzed the 46 cases of adverse events of nursing medication reported by system in the First Affiliated Hospital of Xiamen University after implementing the information drug close-loop management mode(from January to December 2018).Among the 46 cases of events,we analyzed the classifications,causes and links of error and compared those events with adverse events of nursing medication before implementing the information drug close-loop management mode in 2017.Results After carrying out the drug close-loop management,the adverse events of medication declined compared with that in 2017,but there was no statistical difference(P>0.05).The adverse events included 17(17/46,36.96%)errors in identification,8(8/46,17.39%)medication omissions,7(7/46,15.22%)errors in dose and 5(5/46,10.87%)errors in route.The links of medication errors were mainly in drug dispensing(26 cases)and arranging(14 cases).Conclusions Adverse events of medication most often occur in drug dispensing.The most common errors were misidentification.Nursing managers should formulate the preventive intervention based on the classifications and characteristics of adverse events in nursing medication administering,and monitor as well as improve the rate of sweeping code in drug close-loop,strength training for nurses,and check the drug dispensing and arranging well.

关 键 词：护士 信息化 闭环管理 给药错误 不良事件 

分 类 号：R47[医药卫生—护理学]