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。
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[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. |
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