Intravenous fluid prescribing errors in children: Mixed methods analysis of critical incidents.
Intravenous fluid prescribing errors in children: Mixed methods analysis of critical incidents.
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DOI：
10.1371/journal.pone.0186210
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发表时间：
2017
期刊：
影响因子：
3.7
通讯作者：
Dornan T
中科院分区：
文献类型：
--
作者：
Conn RL;McVea S;Carrington A;Dornan T
最近的国家健康与护理卓越研究所（NICE）指南旨在改善儿童静脉（IV）液体处方，但关于液体处方错误如何以及为什么发生的现有证据有限。通过教育和系统设计，研究这一点可以导致更有效的执行。识别实践中报告的IV液体处方错误类型分析导致错误的因素为教育工作者和负责设计系统的人员提供指导混合方法观察性研究，该研究分析了2011年至2015年英国二级保健中发生的与0-16岁儿童IV液体处方错误相关的关键事件报告。我们量化了错误的特征和类型，然后定性分析了叙述性描述，确定了潜在的影响因素。在分析的40起事件中，主要错误类型是液体速率不正确、溶液选择不当和处方图表填写不正确。处方医生必须与复杂的患者进行谈判，与其他从业者和团队进行互动，以及具有挑战性的工作环境;这些相互关联的因素导致了错误。这项研究强调了在实践中报告的IV液体处方错误的多样性和复杂性。虽然这些调查结果具有严重事件报告的固有局限性，但它们指出了教育和系统设计方面的潜在改进领域。在上下文中实践处方，在许多专业中引导医生谁有助于照顾儿童，并教育他们与护士和药剂师联合工作，可以帮助减少错误。
Recent National Institute for Health and Care Excellence (NICE) guidelines aim to improve intravenous (IV) fluid prescribing for children, but existing evidence about how and why fluid prescribing errors occur is limited. Studying this can lead to more effective implementation, through education and systems design. Identify types of IV fluid prescribing errors reported in practice Analyse factors that contribute to errors Provide guidance to educators and those responsible for designing systems Mixed methods observational study which analysed critical incident reports relating to IV fluid prescribing errors in children aged 0–16, occurring between 2011 and 2015 in UK secondary care. We quantified characteristics and types of errors, then qualitatively analysed narrative descriptions, identifying underlying contributing factors. In the 40 incidents analysed, principal types of errors were incorrect rate of fluids, inappropriate choice of solution, and incorrect completion of prescription charts. Prescribers had to negotiate complex patients, interactions with other practitioners and teams, and challenging work environments; errors resulted from these inter-related contributing factors. This study highlights the diverse range and complex nature of IV fluid prescribing errors reported in practice. While these findings have the inherent limitations of critical incident reports, they point to areas of potential improvement in education and systems design. Practising prescribing in context, inducting doctors within the many specialties who contribute to care of children, and educating them in joint working with nurses and pharmacists could help reduce errors.