以质量求发展，以服务铸品牌

护理学报 ›› 2022, Vol. 29 ›› Issue (7): 32-35.doi: 10.16460/j.issn1008-9969.2022.07.032

• 护理管理 • 上一篇    下一篇

护理人员接近失误事件认知的质性研究

田云伟1a, 李善玲1b, 田文雯2, 李维果3, 邵琴1c   

  1. 1.华中科技大学同济医学院附属梨园医院a.护理部; b.党委办公室; c.骨科,湖北 武汉 430077;
    2.华中科技大学同济医学院 护理学院,湖北 武汉430030;
    3.荆楚理工学院,湖北 荆门 448000
  • 收稿日期:2021-11-04 出版日期:2022-04-10 发布日期:2022-05-10
  • 通讯作者: 李善玲（1963-）,女,湖北武汉人,硕士,主任护师,硕士研究生导师。E-mail: 495358239@qq.com
  • 作者简介:田云伟（1997-）,女,山西长治人,本科学历,硕士研究生在读。
  • 基金资助:
    四川省科技厅国际合作研究项目（2019YFS0026）; 四川大学华西护理学科发展专项基金（HXHL20034）

Qualitative Research of Cognition on Near-miss Events in Nursing Staff

TIAN Yun-wei1a, LI Shan-ling1b, TIAN Wen-wen2, LI Wei-guo3, SHAO Qin1c   

  1. 1a. Dept. of Nursing Administration; 1b. Party Committee Office; 1c. Dept. of Orthopedics, Liyuan Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430077, China;
    2. School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China;
    3. Jingchu University of Technology, Jingmen 448000, China
  • Received:2021-11-04 Online:2022-04-10 Published:2022-05-10

PDF (PC)

620

赞

摘要： 目的 探讨护理人员对接近失误事件的认知,为采取针对性措施促进前瞻性风控管理提供参考。方法 采用质性研究中的现象学研究方法,对19名护士进行半结构式深度访谈,采用Colaizzi 7步分析法对资料进行整理分析。结果 共提炼出5个主题：护理人员普遍知晓接近失误事件的重要性、接近失误事件相关认知欠缺、对接近失误事件敏感性不足、接近失误事件管理制度和措施不完善、接近失误事件发生的影响因素。结论 护理管理者应关注造成接近失误事件的因素,根据护理人员接近失误事件认知状况,针对性制定管理策略以降低接近失误事件发生率,提高报告率。

关键词: 护理人员, 接近失误事件, 认知, 质性研究, 护理管理

Abstract: Objective To explore the cognition of near-miss events in nursing staff, and to provide reference for adopting targeted measures to promote prospective risk control management.Methods With phenomenological research methods in qualitative research, an in-depth semi-structured interview was conducted among 19 nurses, and the data were sorted and analyzed by using the Colaizzi 7-step analysis method. Results Five themes were extracted: the perceived significance of near-miss events, lack of awareness related to near-miss events, insufficient sensitivity to near-miss events, imperfect management systems and measures for near-miss events, and the influence factors of near-miss events. Conclusion Nursing managers should pay attention to the risk factors of near-miss events, and formulate management strategies according to the cognition on near-miss events to reduce its incidence and elevate the reporting rate.

Key words: nursing staff, near-miss event, cognition, qualitative research, nursing administration

中图分类号: 

  • R197.323.4
[1] World Health Organization.Global Patient Safety Action Plan2021-2030[EB/OL]. (2021-08-03) [2021-10-30]. https://www.who.int/publications/i/item/9789240032705.
[2] Noor NHM, Joibe KF, Hasan MN.Prevalence of Near-Miss Events of Transfusion Practice and Its Associated Factors amongst House Officers in a Teaching Hospital[J]. Oman Med J, 2021,36(2): e249. DOI:10.5001/omj.2021.55.
[3] 中国医院协会.中国医院质量安全管理:第4部分医疗管理:T/CHAS 10-4-6-2018[S].北京:中国医院协会,2018.
[4] 于淼,王建辉,刘学明,等.护士给药接近失误报告障碍的影响因素分析[J].中华护理杂志, 2020,55(9):1304-1309. DOI:10.3761/j.issn.0254-1769.2020.09.004.
[5] Weprin S, Crocerossa F, Meyer D, et al.Risk Factors and Preventive Strategies for Unintentionally Retained Surgical Sharps: A Systematic Review[J]. Patient Saf Surg, 2021,15(1):24. DOI:10.1186/13037-021-00297-3.
[6] 张瑜慧,卫晓静,景孟娟,等.接近失误管理在危重症患者院内转运的应用效果研究[J].护士进修杂志, 2021,36(11):1011-1014. DOI:10.16821/j.cnki.hsjx.2021.11.011.
[7] 刘明. Colaizzi七个步骤在现象学研究资料分析中的应用[J].护理学杂志, 2019,34(11):90-92. DOI:10.3870/j.issn.1001-4152.2019.11.090.
[8] Hewitt TA, Chreim S.Fix and Forget or Fix and Report: A Qualitative Study of Tensions at the Front Line of Incident Reporting[J]. BMJ Qual Saf, 2015,24(5):303-310. DOI:10.1136/bmjqs-2014-003279.
[9] Africa L, Shinners JS.Tracking Medical Errors and Near Misses in the New Graduate Registered Nurse[J]. Nursing Forum, 2020,55(2):174-176. DOI:10.1111/nuf.12412.
[10] Tramacere F, Sardaro A, Arcangeli S, et al.Safety Culture to Improve Accidental Events Reporting in Radiotherapy[J]. J Radiol Prot, 2021,41(4):1317-1327. DOI:10.1088/1361-6498/ac0c01.
[11] Lu H, Wu T, Shao Y, et al.Safety-Specific Leadership, Goal Orientation, and Near-miss Recognition: The Cross-Level Moderating Effects of Safety Climate[J]. Front Psychol, 2019,10:1136. DOI:10.3389/fpsyg.2019.01136.
[12] 于淼,王建辉,赵彩杰,等.领导-成员交换关系在变革型领导与护理差错管理氛围间的中介作用[J]. 护理学杂志, 2020,35(2):9-11.DOI:10.3760/cma.j.cn115682-20200320-01988.
[13] 冯婷婷,张欣,谭玲玲,等.护理接近失误管理的研究进展[J].中华护理杂志,2020, 55(1):153-157. DOI:10.3761/j.issn.0254-1769.2020.01.027.
[14] 周淑芬,刘翠青,谢翠媚,等.护理不良事件与安全隐患上报双轨化管理的实施效果[J]. 护理学报, 2018, 25(5):24-26. DOI:10.16460/j.issn1008-9969.2018.05.024.
[15] Milne-Ives M, de Cock C, Lim E, et al. The Effectiveness of Artificial Intelligence Conversational Agents in Health Care: Systematic Review[J]. J Med Internet Res, 2020,22(10): e20346. DOI:10.2196/20346.
[16] 刘光英,卢振玲,高辉.手术室护理质量管理中质控小组与专业小组联合的实践[J]. 中国护理管理,2017,17(7):902-906. DOI:10.3969/j.issn.1672-1756.2017.07.011.
[17] Jeffs L, Berta W, Lingard L, et al.Learning from Near Misses: from Quick Fixes to Closing off the Swiss-Cheese Holes[J]. BMJ Qual Saf, 2012,21(4):287-294. DOI:10.1136/bmjqs-2011-000256.
[18] Haas EJ, Demich B, McGuire J. Learning from Workers'Near-miss Reports to Improve Organizational Management[J]. Min Metall Explor, 2020,37(3):873-885. DOI:10.1007/s42461-020-00206-9.
[19] Craker NC, Myers RA, Eid J, et al.Nursing Interruptions in a Trauma Intensive CareUnit: A Prospective Observational Study[J]. J Nurs Adm, 2017,47(4):205-211. DOI:10.1097/NNA.0000000000000466.
[20] 王伟,赵小静,孔冬,等.护理用药过程中中断事件现状调查[J].中国护理管理, 2020,20(3):436-441. DOI:10.3969/j.issn.1672-1756.2020.03.024.
[21] Hong J, Kim M, Suh EE, et al.Comparison of Fatigue, Quality of Life, Turnover Intention, and Safety Incident Frequency between 2-Shift and 3-Shift Korean Nurses[J]. Int J Environ Res Public Health, 2021,18(15):7953. DOI:10.3390/ijerph18157953.
[1] 吴超瑜, 刘尚昆. 麻醉恢复室护士危机管理能力的质性研究[J]. 护理学报, 2025, 32(3): 17-21.
[2] 谭雯渲, 张容, 张立力, 王玮, 邵艳红, 方庆虹, 朱瑾. 心脏移植患者手术决策困境的现象学研究[J]. 护理学报, 2025, 32(3): 69-73.
[3] 曹敏, 张培莉, 侯晓雅, 高超越, 郭林芳, 李滢. ABC-X模型下结直肠癌化疗患者照顾者营养照护体验的质性研究[J]. 护理学报, 2025, 32(2): 13-18.
[4] 孙娟, 李亚莉, 马安娜, 王华, 张会敏. 护理研究生对社区护理实践思政教学体验的质性研究[J]. 护理学报, 2025, 32(1): 19-23.
[5] 王语, 赵慧杰, 肖梦伟, 范硕宁, 孙佳丽, 王珂心, 苏炫, 杨滢瑞. 糖尿病视网膜病变患者硅油填充期间疾病体验与应对的质性研究[J]. 护理学报, 2025, 32(1): 68-72.
[6] 文敏, 陈兵, 周永玲, 刘娟, 朱晓丹. 精神分裂症患者基于移动医疗APP的认知矫正联合干预方案的构建[J]. 护理学报, 2024, 31(9): 1-4.
[7] 冯春玲, 胡夏晴, 徐琳, 蔡鑫健, 徐琴鸿. 基于社会生态系统理论的电话指导公众实施心肺复苏行为动机及需求的质性研究[J]. 护理学报, 2024, 31(9): 66-71.
[8] 何娇, 刘义兰, 官春燕, 韩燕红, 陈睿, 胡德英. 基于泰勒原理的医院护理人文关怀培训课程体系的构建[J]. 护理学报, 2024, 31(8): 13-17.
[9] 曹依丽, 王玲, 王灿, 陈燕华, 秦虹云. 精神分裂症住院患者家属资源取向的质性研究[J]. 护理学报, 2024, 31(8): 74-78.
[10] 马瑞瑞, 范晓莉, 徐姝娟, 张伟, 陈婷, 谈飞飞. 护士参与终末期患者临终决策体验的质性研究[J]. 护理学报, 2024, 31(7): 6-11.
[11] 龙瑶, 卢春凤, 冯志仙. 临床护士对横向领导者特质感知的质性研究[J]. 护理学报, 2024, 31(7): 27-31.
[12] 张颖, 车晓艳, 万婠, 秦雪, 张恩思, 崇武, 郑淑娟. 我国性治疗护士工作范畴和核心能力的质性研究[J]. 护理学报, 2024, 31(7): 68-72.
[13] 孙素亚, 陈亚梅, 陈伟仙, 薄瑾, 刘晓红, 黄燕, 林梦月. 认知性访谈在过渡期炎症性肠病患者过渡准备量表文化调适中的应用[J]. 护理学报, 2024, 31(6): 1-5.
[14] 张露心, 焦延超, 文稀, 田利, 王婷, 田凤美, 李惠玲. 护理本科生在“慕课西行”同步课堂学习体验的质性研究[J]. 护理学报, 2024, 31(6): 30-34.
[15] 陈芳, 杨旻斐, 姚晓月, 周诗博. 杭州亚运会定点医院院内护理保障体系的建设与实践[J]. 护理学报, 2024, 31(6): 35-38.
Viewed
Full text


Abstract

Cited
  Shared   
No Suggested Reading articles found!