Medication Safety Event Reporting: Factors That Contribute to Safety Events During Times of Organizational Stress.
Medication Safety Event Reporting: Factors That Contribute to Safety Events During Times of Organizational Stress.
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药物安全事件报告：组织压力期间导致安全事件的因素。
DOI：
10.1097/ncq.0000000000000720
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发表时间：
2024
影响因子：
1.2
通讯作者：
Nuckols,TerylK
中科院分区：
文献类型：
--
作者：
Cohen,TaraN;Berdahl,CarlT;Coleman,BerniceL;Seferian,EdwardG;Henreid,AndrewJ;Leang,DonnaW;Nuckols,TerylK
背景：在组织压力时期提交的事件报告可能会揭示独特的见解。目的：了解医院事件报告中关于工作系统因素在冠状病毒疾病-2019年(新冠肺炎)手术期间如何影响用药安全的见解。方法：我们从一个学术医学中心(2020年12月至2021年1月)随机选择100份药物安全事件报告，识别差错和差错，并使用人因分析与分类系统-医疗分类系统对工作系统因素进行分类。结果：在35个差错/差错中，事件报告描述了导致因素(平均1.3个/报告)，涉及技能错误(n=20)，沟通(n=8)，和工具/技术(n=4)。记者将7起事件与COVID-19联系起来。结论：在新冠肺炎激增期间，基于技能的差错是最常见的用药安全事件促成因素。记者很少认为事件与新冠肺炎有关，尽管护士人数激增给他们带来了巨大的压力。今后改进事故报告效用的努力应强调描述工作系统因素的重要性。
Background:Incident reports submitted during times of organizational stress may reveal unique insights.Purpose:To understand the insights conveyed in hospital incident reports about how work system factors affected medication safety during a coronavirus disease-2019 (COVID-19) surge.Methods:We randomly selected 100 medication safety incident reports from an academic medical center (December 2020 to January 2021), identified near misses and errors, and classified contributing work system factors using the Human Factors Analysis and Classification System-Healthcare.Results:Among 35 near misses/errors, incident reports described contributing factors (mean 1.3/report) involving skill-based errors (n= 20), communication (n= 8), and tools/technology (n= 4). Reporters linked 7 events to COVID-19.Conclusions:Skill-based errors were the most common contributing factors for medication safety events during a COVID-19 surge. Reporters rarely deemed events to be related to COVID-19, despite the tremendous strain of the surge on nurses. Future efforts to improve the utility of incident reports should emphasize the importance of describing work system factors.