摘要: 目的 对急诊给药错误的发生特点、风险预测、安全护理实践进行综述,为临床护理实践提供参考。方法 检索国内外相关文献,从急诊给药错误发生高危因素,给药错误发生评估工具,急诊给药安全干预策略的开展形式及效果等方面进行综述。结果 临床护理实践中,通过识别急诊给药错误高危因素,并使用错误风险识别工具,进行早期风险识别及预防,采取综合干预措施以减少急诊给药错误发生。结论 我国急诊给药安全干预策略研究较少,借鉴国内外相关文献,探索适合我国急诊护理工作特点的给药安全干预策略。
中图分类号:
[1] 韩圆, 陈小芳, 翟惠敏. 34家综合医院急诊科护士工作环境现状及影响因素分析[J]. 护理学报,2019,26(17):45-50.DOI:10.16460/j.issn1008-9969.2019.17.045 [2] 李璐柳,王建宁,周松.136名急诊科护士情绪劳动水平分析[J].护理学报,2019,26(6):43-46.DOI:10.16460/j.issn1008-9969.2019.06.043. [3] Weant KA, Bailey A, Baker S.Strategies for Reducing Medication Errors in the Emergency Department[J].Open Access Emerg Med,2014,23(6):45-55.DOI:10.2147/oaem.s64174. [4] Millichamp T, Johnston ANB.Interventions to Support Safe Medication Administration by Emergency Separtment Nurses: An Integrative Review[J]. Int Emerg Nurs, 2020, 49:100811.DOI:10.1016/j.ienj.2019.100811. [5] Hosseini-Marznaki Z, Pouy S, Salisu WJ, et al.Medication Errors Among Iranian Emergency Nurses: A Systematic Review[J]. Epidemiol Health,2020,42:e2020030.DOI:10.4178/epih.e2020030. [6] 刘然. PDA移动扫描系统在急诊重症患者安全用药中的应用[J].中国病案,2016,17(1):30-31. [7] 何福鲜,潘丽梅,莫崇爱,等. “双人双边同时核对”用于急诊科预防注射剂用药错误的实践[J].护士进修杂志,2020,35(12):1143-1145.DOI:10.16821/j.cnki.hsjx.2020.12.020. [8] Akhil N, Thomas PP, Shivaraj DR, et al.Assessment, Evaluation, and Analysis of the Medication Errors of the Patients Admitted at The Emergency Department of a Tertiary Care Teaching Hospital of a South Indian City[J]. Asian J Pharm Clin Res,2017,10(5):161-165.DOI:10.22159/ajpcr.2017.v10i5.17170. [9] Andreu MM, Gómez TS, López MA, et al.PS-064 Medication Errors in an Emergency Department Observation Unit[J]. Eur J Hosp Pharm, 2016, 23(Suppl 1):A241-A242.DOI:10.1136/ejhpharm-2016-000875.548. [10] Hirata KM, Kang AH, Ramirez GV, et al.Pediatric Weight Errors and Resultant Medication Dosing Errors in The Emergency Department[J]. Pediatr Emerg Care,2019,35(9):637-642.DOI:10.1097/PEC.0000000000001277. [11] Wu HF, Yu S, Lan YH, et al.Medication Errors in Emergency Rooms, Intensive Care Units and Pediatric Wards[J]. Hu Li Za Zhi,2012,59(2):93-98. [12] Pérez-Díez C, Real-Campaña JM, Noya-Castro MC, et al.Medication Errors in a Hospital Emergency Department: Study of The Current Situation and Critical Points for Improving Patient Safety[J]. Emergencias,2017,29(6):412-415. [13] Shitu Z, Aung MMT, Tuan TH, et al.Prevalence and Characteristics of Medication Errors at an Emergency Department of a Teaching Hospital in Malaysia[J]. BMC Health Serv Res,2020, 20(1):1-7.DOI:10.1186/s12913-020 -4921-4 [14] Park JH, Lee EN.Influencing Factors and Consequences of Near Miss Experience in Nurses' Medication Error[J]. J Korean Acad Nurs,2019, 49(5):631-642.DOI:10.4040/jkan.2019.49.5.631. [15] Yu X, Li C, Gao X, et al.Influence of the Medication Environment on the Unsafe Medication Behaviour of Nurses: A Path Analysis[J]. J Clin Nurs,2018,27(15/16):2993-3000.DOI:10.1111/jocn.14485. [16] Audurier Y, Roubille C, Manna F, et al.Development and Validation of a Score to Assess Risk of Medication Errors Detected During Medication Reconciliation Process at Admission in Internal Medicine Unit: SCOREM Study[J]. Int J Clin Pract,2021,75(2):e13663.DOI:10.1111/ijcp.13663. [17] Berg TA, Li X, Sawhney R, et al.Agent-Based Modeling Simulation of Nurse Medication Administration Errors[J]. Comput Inform Nurs, 2020,39(4):187-197.DOI:10.1097/CIN. 0000000000000684. [18] Paparella SF.Alignment with the ISMP 2018-2019 Targeted Medication Safety Best Practices for Hospitals[J]. J Emerg Nurs, 2018, 44(2):191-194.DOI:10.1016/j.jen.2017.11.014. [19] Kanwar M, Irvin CB, Frank JJ, et al.Confusion About Epinephrine Dosing Leading to Iatrogenic Overdose:A Life-Threatening Problem with a Potential Solution[J]. Ann Emerg Med,2010, 55(4):341-344.DOI:10.1016/j.annemergmed.2009.11.008. [20] Moreira ME, Hernandez C, Stevens AD, et al. Color-Coded Prefilled Medication Syringes Decrease Time to Delivery and Dosing Error in Simulated Emergency Department Pediatric Resuscitations[J]. Ann Emerg Med,2015,66(2):97-106.e3.DOI:10.1016/j.annemergmed.2014.12.035. [21] 谭然, 曾宪涛, 曹英娟,等.用药错误预防及管理临床实践指南的质量评价与内容分析[J].中华护理杂志,2019,54(6):867-873. [22] Glover N.Challenges Implementing Bar-coded Medication Administration in the Emergency Room in Comparison to Medical Surgical Units[J]. Comput Informatics Nurs,2013,31(3):133-141.DOI:10.1097/NXN.0b013e318280ef5e. [23] Bonkowski J, Carnes C, Melucci J, et al.Effect of Barcode-Assisted Medication Administration on Emergency Department Medication Errors[J]. Acad Emerg Med,2013,20(8):801-806.DOI:10.1111/acem.12189. [24] Owens K, Palmore M, Penoyer D, et al.The Effect of Implementing Bar-code Medication Administration in an Emergency Department on Medication Administration Errors and Nursing Satisfaction[J].J Emerg Nurs,2020,46(6):884-891.DOI:10.1016/j.jen.2020.07.004. [25] 沈佳妮. 急诊科抢救室移动药柜的设置与成效[J].中医药管理杂志,2019,27(20):229-230. [26] Fanning L, Jones N, Manias E.Impact of Automated Dispensing Cabinets on Medication Selection and Preparation Error Rates in an Emergency Department: A Prospective and Direct Observational Before-and-after Study[J].J Eval Clin Pract,2016,22(2):156-163.DOI:10.1111/jep.12445. [27] 沈秀兰,陈丽霞,刘金恒,等.智能电子药柜在急诊抢救室中的应用[J].中华危重症医学杂志:电子版,2019,12(2):123-125.DOI:10.3877/cma.j.issn.1674-6880.2019.02.011. [28] Koyama AK, Maddox CSS, Li L, et al.Effectiveness of Double Checking to Reduce Medication Administration Errors: A Systematic Review[J].BMJ Qual Saf,2020,29(7):595-603.DOI:10.1136/bmjqs-2019-009552. [29] Alves B, Andrade T, Santos SC, et al.Harm Prevalence Due to Medication Errors Involving High-alert Medications: A Systematic Review[J].J Patient Saf,2020,17(1):e1-e9. [30] Douglass AM, Elder J, Watson R, et al.A Randomized Controlled Trial on the Effect of a Double Check on the Detection of Medication Errors[J].Ann Emerg Med,2018,71(1):74-82.DOI:https://DOI.org/10.1016/j.annemergmed.2017.03.022. [31] Siebert JN, Ehrler F, Combescure C, et al.A Mobile Device App to Reduce Time to Drug Delivery and Medication Errors During Simulated Pediatric Cardiopulmonary Resuscitation: A Randomized Controlled Trial[J].J Med Internet Res,2017,19(2):e31.DOI:10.2196/jmir.7005. [32] Siebert JN, Bloudeau L, Ehrler F, et al.A Mobile Device App to Reduce Prehospital Medication Errors and Time to Drug Preparation and Delivery by Emergency Medical Services During Simulated Pediatric Cardiopulmonary Resuscitation: Study Protocol of a Multicenter, Prospective, Randomized Controlled trial[J]. Trials,2019,20(1):634.DOI:10.1186/s13063-019-3726-4. [33] 李红云, 汪惠, 边书芹,等.医疗失效模式与效应分析在儿科静脉用药调配中的应用[J].护理学报,2020,27(20):12-16.DOI:10.16460/j.issn1008-9969.2020.20.012. [34] 陈丽鸥, 应波, 闫素英,等.多学科管理模式下口服给药流程再造效果评价[J].护理学报,2020,27(8):16-19.DOI:10.16460/j.issn1008-9969.2020.08.016. [35] 陈秋菊, 刘瑛, 黄萍,等.应用HFMEA促进急诊抢救室用药流程信息化的实践[J].护理学杂志,2017,32(24):50-52.DOI:10.3870/j.issn.1001-4152.2017.24.050. [36] 方丹枫. HFMEA模式在促进抢救室用药流程信息化中的作用[J]. 中医药管理杂志,2020,28(33):57-59. [37] 曹悦玲, 冯玉军. 5S管理在护士给药安全管理中的应用与效果[J]. 世界中医药,2016,11(B03):1328-1329. [38] Lee SB, Lee LL, Yeung RS, et al.A Continuous Quality Improvement Project to Reduce Medication Error in the Emergency Department[J]. World J Emerg Med,2013,4(3):179-182.DOI:10.5847/wjem.j.issn.1920-8642.2013.03.004. [39] Wahr JA, Abernathy JH, Lazarra EH, et al.Medication Safety in the Operating Room: Literature and Expert-based Recommendations[J]. Br J Anaesth, 2017,118(1):32-43.DOI:10.1093/bja/aew379. [40] Kane-Gill SL, Dasta JF, Buckley MS, et al.Clinical Practice Guideline: Safe Medication Use in the ICU[J]. Crit Care Med,2017, 45(9):e877-e915.DOI:10.1097/CCM.00000 00000002533. [41] Benkelfat R, Gouin S, Larose G, Bailey B.Medication Errors in the Management of Anaphylaxis in a Pediatric Emergency Department[J]. J Emerg Med,2013,45(3):419-425.DOI:https://DOI.org/10.1016/j.jemermed.2012.11.069. |
[1] | 杜易梅, 刘莉, 郭立丽, 卢吉, 付苗苗, 刘杰. 妇科恶性肿瘤患者性健康研究进展[J]. 护理学报, 2025, 32(4): 28-33. |
[2] | 张静, 彭焕椽, 陈佳, 鲁永锦, 刘克玄, 侯晓敏. 成人体外循环心脏手术患者预防手术部位感染的最佳证据总结[J]. 护理学报, 2025, 32(4): 41-47. |
[3] | 李垚, 陈小敏, 夏敏, 吴茜, 张琳, 陈叡喆, 葛莉丽, 吴逸梅. 肿瘤患者衰弱评估工具应用的范围综述[J]. 护理学报, 2025, 32(4): 48-52. |
[4] | 刘璐, 朱钰, 曹义, 张华, 彭玉娜. 腹腔热灌注化疗患者术中实施不同目标体温管理的效果观察[J]. 护理学报, 2025, 32(4): 59-63. |
[5] | 李疆伟, 王树君, 李长仔, 胡宝山, 焦桂梅, 张卫红. 基于压力应对理论的护理干预对结直肠癌术后永久性肠造口患者心理压力、负性情绪及自我管理的影响[J]. 护理学报, 2025, 32(4): 64-69. |
[6] | 龚祖华, 孙丽, 谭璇, 张悦, 施丹, 程娟娟. 肝胆外科术后患者基础体征采集-比对-识别隐匿型病情变化的效果观察[J]. 护理学报, 2025, 32(4): 74-78. |
[7] | 李苗苗, 熊莉娟, 齐磊, 李敏, 向御婷. 基于Ridit分析法和秩和比法的疾病诊断相关分组在护理绩效管理中的应用[J]. 护理学报, 2025, 32(3): 22-26. |
[8] | 王小叶, 安俊红, 刘倩, 任琴, 高瑞琴, 范丽红. 共享决策在糖尿病足患者中应用的研究进展[J]. 护理学报, 2025, 32(3): 32-37. |
[9] | 焦雪萍, 王志稳, 韩舒羽. ICU老年患者躁动行为的干预研究进展[J]. 护理学报, 2025, 32(3): 38-42. |
[10] | 陈恩琳, 莫丰菱, 庄泽明, 张明哲, 周佳坤, 黄丽芳, 纪龙飞, 张莉芳. 脑卒中单侧空间忽略评估工具的范围综述[J]. 护理学报, 2025, 32(3): 43-49. |
[11] | 李若雨, 刘鑫, 林萍, 陈丹, 林桦. 出院患者用药安全管理的最佳证据总结[J]. 护理学报, 2025, 32(3): 50-55. |
[12] | 杨小娟, 毛孝容, 王静, 江华, 李蓉, 樊宇, 文青, 李林章, 陈晓容. 成人重度烧伤患者早期肠内营养管理的最佳证据总结[J]. 护理学报, 2025, 32(3): 56-61. |
[13] | 朱天顺, 朱可可, 薛会元, 焦聪聪, 魏长慧, 王贺. 信息框架效应理论在健康管理领域应用的范围综述[J]. 护理学报, 2025, 32(2): 44-49. |
[14] | 刘硕怡, 熊莉娟, 李凌, 王玉梅, 何嘉, 李鑫, 袁淑蕾, 郭雪琴, 王暘婧, 张慧娟. 老年住院患者衰弱预防及管理临床实践指南的质量评价及内容分析[J]. 护理学报, 2025, 32(2): 50-55. |
[15] | 闫亚铃, 乐美妮, 姚桃琴, 王雪莲, 姜建玲, 辛艺. 老年胃肠肿瘤患者围手术期衰弱管理方案的构建[J]. 护理学报, 2025, 32(2): 74-78. |
|