系统故障的多个点是息治疗中持续的皮下输液安全事件的基础:混合方法分析:
Amy Brown1,2, Sarah Yardley1,3,4, Ben Bowers1,5,6
1Marie Curie Research Centre, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK.
Palliative medicine
|October 24, 2024
概括
在息治疗中,持续的皮下注射容易发生因系统和人为因素造成的事故. 改善药物治疗过程和护理连续性对于患者安全至关重要.
科学领域:
- 抚慰性护理医学 抚慰性护理医学
- 患者安全研究 患者安全研究
- 药物安全 药物安全
背景情况:
- 持续的皮下输液 (CSCI) 涉及约25%的息药物事件.
- 复杂的结构和人为因素导致CSCI干预的高风险性质.
- 缺乏对安全关键的CSCI护理的详细分析,阻碍了改进工作.
研究的目的:
- 了解在息治疗中与CSCI相关的安全事件及其对患者和家人的影响.
- 通过分析CSCI药物错误的反复事件和促成因素来确定系统改进的具体目标.
主要方法:
- 对涉及CSCI的息药物事件进行了混合方法分析.
- 量化描述性分析使用了患者安全 (PISA) 分类系统.
- 在2016年至2021年期间,对7506起报告的事件进行了自由文本报告的定性叙事分析.
主要成果:
- 超过1300起事件涉及CSCI,其中72%详细说明了对患者的伤害.
- 药物监测/供应 (31%),管理 (29%) 和处方 (20%) 的故障是不适当使用药物的首要原因.
- 经常出现的因素包括护理中断,时间/人员不足,以及对协议不熟悉,导致心理伤害.
结论:
- 需要进行系统性改进,以便及时提供药物/设备和协调使用CSCI.
- 加强沟通和跨环境的护理连续性至关重要.
- 改善事件报告培训是必要的,以确定更安全的CSCI实践的精确目标.
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