墨西哥一家儿童医院的护士报告的与药物不良事件相关的危险因素
Rosa María Hidalgo-Velasco1, Graciela Martínez-Velasco2, Martha Martínez-Salazar3
1Subjefatura de Enfermería, Instituto Mexicano del Seguro Social, Centro Médico Nacional Siglo XXI, Hospital de Pediatría, División de Educación Médica, Mexico City, Mexico.
Enfermeria intensiva
|February 5, 2025
概括
工作超负荷是儿科药物管理中不良事件的重要危险因素. 实施强大的事件报告系统和利用根源原因分析可以提高患者的安全.
科学领域:
- 儿科患者的安全性
- 药物管理错误可能导致药物错误.
- 改善医疗保健质量 改善医疗保健质量
背景情况:
- 患者安全事件,包括不良事件,在儿科药物管理期间继续发生.
- 识别导致这些事件的因素对于制定有效的预防策略至关重要.
研究的目的:
- 根据护士报告,识别儿科药物管理期间与不良事件相关的危险因素.
- 通过根源原因分析分析导致的因素.
主要方法:
- 一项横截面研究分析了来自Vencer II系统的140起事件报告 (2021年1月至10月).
- 用根源原因分析来调查与不良事件相关的38个因素.
- 描述性和推断性统计数据被用于数据分析.
主要成果:
- 在140份事故报告中,有116份 (83.0%) 是不良事件,24份 (17.0%) 是准故障.
- 工作超负荷与不良事件有显著的相关性 (OR=3.24,p=0.008).
- 与预期相反,看起来相似,听起来相似 (LASA) 药物和双重检查的遗漏被发现具有保护性 (分别为OR=0.323,p=0.017和OR=0.39,p=0.047).
结论:
- 工作超负荷是一个关键的风险因素,需要从客观和感知护理角度进行评估.
- 记录的事件通知和响应系统提高了机构的透明度和勤勉性.
- 根源原因分析和石川图是识别事故导致因素的有价值工具,应该整合到像VENCER II这样的现有系统中.
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