护士给药作业中人因失误类型与失误诱发因素间的关联研究  

The Association between Human Error Types and Error Inducing Factors in Nursing Medication Administration Process

作　　者：金海哲 张家浩 刘洋[1] 龚子博 赵奕楠[3] JIN Hai-zhe;ZHANG Jia-hao;LIU Yang;GONG Zi-bo;ZHAO Yi-nan(School of Business Administration,Northeastern University,Shenyang 110167,China;Department of Radiology,Shengjing Hospital of China Medical University,Shenyang 110136,China;Department of Neurology,The First Hospital of China Medical University,Shenyang 110002,China)

机构地区：[1]东北大学工商管理学院,沈阳110167 [2]中国医科大学附属盛京医院放射线科,沈阳110136 [3]中国医科大学附属第一医院神经内科,沈阳110002

出　　处：《人类工效学》2023年第5期27-31,共5页Chinese Journal of Ergonomics

摘　　要：目的护士给药失误是医疗过程中最多的失误,本研究从作业流程优化角度探讨预防和减少护士给药失误诱发的因素。方法以护士给药过程为研究对象,随机抽取某地3家合作医疗机构收集实际医疗失误案例411例,采用根因分析法(Root Cause Analysis)提取人因失误类型与失误因素,基于Apriori算法探讨失误类型与失误因素间的关联强度。结果(1)提取了6种失误类型与6种失误诱发因素;(2)定量表达了不同失误诱发因素对人因失误类型的影响,其支持度在5.8%-11%,置信度在30.10%-96.30%,提升度在1.39-6.29。(3)开展了给药作业流程的失误分析,为失误防范提供了具体指向。结论提取的医疗人因失误类型、失误诱发因素可为医疗管理者的失误防范与作业流程优化提供参考依据,同时进一步完善医疗人因失误相关理论。Objective Nurse medication errors are among the most common mistakes in the medical process.This study aims to explore factors that contribute to the occurrence of nurse medication errors from the perspective of workflow optimization and prevention.Methods The study focused on the nurse medication administration process and randomly selected 411 actual medical error cases from three collaborating healthcare institutions in a specific location.Root Cause Analysis was employed to identify human error types and contributing factors,while the Apriori algorithm was used to investigate the strength of associations between error types and contributing factors.Results(1)Six error types and six contributing factors were identified.(2)The study quantitatively expressed the impact of different contributing factors on human error types,with support ranging from 5.8%to 11%,confidence ranging from 30.10%to 96.30%,and lift ranging from 1.39 to 6.29.(3)Error analysis of the medication administration workflow was conducted,providing specific guidance for error prevention.Conclusion The extracted human error types and contributing factors can serve as a reference for healthcare managers in error prevention and workflow optimization,while also contributing to the enhancement of related theories regarding human errors in healthcare.

关 键 词：人因工程 作业流程优化 护士给药 人因失误 失误诱发因素 关联规则 失误防范 医疗事故 

分 类 号：C939[经济管理—管理学]