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在模拟的军事关键护理空中运输环境中识别和减少胰岛素错误:人类因素方法
Lane L Frasier1, Mark Cheney2,3, Joshua Burkhardt2,4
1Department of Surgery, University of Cincinnati, Cincinnati, OH 45267, USA.
Military medicine
|June 5, 2024
概括
人为因素的干预显著减少了临界护理航空运输 (CCAT) 模拟中的胰岛素药物错误. 训练和认知辅助降低了剂量错误,而动手练习减少了剂量错误.
科学领域:
- 医学模拟和人类因素研究.
- 患者安全和减少药物错误的策略.
- 重症护理和紧急医疗培训.
背景情况:
- 临界护理空运 (CCAT) 的高保真模拟显示了常见的胰岛素药物错误.
- 采用人为因素方法来识别和减轻这些错误.
研究的目的:
- 在CCAT模拟中确定基线胰岛素药物错误率.
- 评估有针对性的干预措施在减少胰岛素药物错误方面的有效性.
- 为了比较不同干预策略对基于决策和基于技能的错误的影响.
主要方法:
- 对22个CCAT模拟的回顾性音频视频审查,以确定基线错误频率.
- 使用人类因素分析分类系统 (HFACS) 将错误分类为基于决策 (剂量) 和基于技能 (管理).
- 实施了两个干预臂:第一臂 (教学课程,实践性胰岛素制备与2人检查) 和第二臂 (第一臂干预加上滑动尺度胰岛素认知辅助器).
主要成果:
- 基线基于决策和基于技能的错误率分别为27.3%.
- 与基线相比,这两个干预组显著减少了基于决策的错误 (组1:9.7%,组2:2.2%). 与手臂1相比,手臂2显示了进一步显著的减少.
- 与基线相比,两只手臂都显著减少了基于技能的错误 (手臂1:1.1%,手臂2:2.9%),两只手臂之间没有显著差异.
结论:
- 高准确度模拟中的描述性错误分析,加上人为因素干预,有效地减少了CCAT中的药物错误.
- 教学培训和认知辅助工具成功减少了基于决策的错误,而实践培训减少了基于技能的错误.
- 建议包括制定SSI临床实践指南,实施2人检查,并将手动胰岛素制备培训纳入维持计划.
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