[논문]환자안전사고 보고서를 통한 간호사 투약오류 분석

구미지

doi:10.22650/jkcnr.2021.27.1.109

환자안전사고 보고서를 통한 간호사 투약오류 분석
Analysis of Medication Errors of Nurses by Patient Safety Accident Reports 원문보기

임상간호연구 = Journal of Korean Clinical Nursing Research, v.27 no.1, 2021년, pp.109 - 119

Abstract ▼ AI-Helper

Purpose: The purpose of this study was to identify and analyze the characteristics of nurses' medication errors during three years. Methods: Retrospective survey study design was used to analyze medication errors by nurses among patient safety accidents. Data were collected for three years from January, 2017 to December, 2019. Data were analyzed using frequency, percentage, 𝑥2-test, and logistic regression with SPSS 26.0 program. Results: Of a total 677 medication errors, 40.6% were caused by nurses. Among the medication errors, near miss (n=154, 56.0%), intravenous bolus injection (n=170, 61.8%), wrong dose (n=102, 37.1%) and carelessness for repetitive work (n=98, 35.6%) were the most common. Medication errors differed by department, and nurses' career, and patient safety accident type. The results of the logistic regression analysis showed that the risk factors of adverse events were medication of fluids (OR=3.93, 95% CI: 1.26~12.27), insulin subcutaneous injection (OR=39.06, 95% CI: 4.58~333.18), and occurrence of extravasation/infiltration (OR=7.26, 95% CI: 1.85~28.53). Conclusion: The simplest and most effective way to prevent medication errors is to keep 5 right, and a differentiated education program according to department and nurse career is needed rather than general education programs. Hospital-level integrated interventions such as a medication barcode system or a team nursing method are also necessary.

주제어

표/그림 (5)

표 Table 1. Characteristics of Medication Errors (N=275)
표 Table 2. Characteristics of Medication Errors by Department (N=275)
표 Table 3. Characteristics of Medication Errors by Nurse's Career (N=275)
표 Table 4. Characteristics of Medication Errors by the Type of Patient Safety Accident (N=275)
표 Table 5. Risk Factors of Adverse Events

참고문헌 (30)

Kim YS, Park KY. Nurses' awareness on healthcare accreditation, work overload, and professional self-concept and their influencing activities of patient safety management among nurses. Journal of the Korean Data Analysis Society. 2014;16(6B):3377-3392.
de Veries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The incidence and nature of in-hospital adverse events: a systematic review. Quality & Safe in Health Care. 2008;17(3):216-223. https://doi.org/10.1136/qshc.2007.023622

상세보기
Kim EK, Lee SY, Eom MR. DISC behavior pattern and medication error by nurses. Journal of Korean Academy of Nursing Administration. 2013;19(1):28-38. https://doi.org/10.11111/jkana.2013.19.1.28

원문보기 상세보기
Kim KS, Kwon SH, Kim JA, Cho SH. Nurses' perception of medication errors and their contributing factors in South Korea. Journal of Nursing Management. 2011;19(3):346-353. https://doi.org/10.1111/j.1365-2834.2011.01249.x

상세보기
Kim JK. The predictive factors of medication errors in clinical nurse [master's thesis]. Daegu: Kyungpook National University; 2019. p. 1-45.
Park JH, Lee EN. Influencing factors and consequences of near miss experience in nurses' medication error. Journal of Korean Academy of Nursing. 2019;49(5):631-642. https://doi.org/10.4040/jkan.2019.49.5.631

원문보기 상세보기
Kim EK, Kang MA, Kim HJ. Experience and perception on patient safety culture of employees in hospitals. Journal of Korean Academy of Nursing Administration. 2007;13(3):321-334.
Bae HG. Relationship of nurse's patient safety culture perception with experience of medication near miss [master's thesis]. Seongnam: Gachon University; 2019. p. 1-60.
Bae JH, Kim J. How the organizational culture in nursing and nurses' communication styles influence the intention to report medication errors. Korean Journal of Medical Ethics. 2016;19 (3):328-339. https://doi.org/10.35301/ksme.2016.19.3.328

상세보기
Kohn LT, Corrigan JM, Donaldson MS. To err is human: Building a safer health system. Washington(DC): National Academies Press; 2000. p. 1-27.
Lee YS, Ryu SY, Park J, Choi SW. The association safety climate and transformational leadership of head nurse with barrier to medication error reporting among nurses in a hospital. Journal of Health Informatics and Statistics. 2016;41(2):147-154. https://doi.org/10.21032/jhis.2016.41.2.147
Reason J. Human error: Models and management. British Medical Journal. 2000;320:768-770. https://doi.org/10.1136/bmj.320.7237.768

상세보기
World Health Organization. Conceptual framework of the international classification for patient safety: Final technical report [Internet]. Version 1.1. Geneve: World Health Organization; 2009 [cited 2020 June 30]. Available from: http://www.who.int/patientsafety/taxonomy/icps_full_report.pdf.
Pierson S, Hansen R, Greene S, Williams C, Akers R, Jonsson M, et al. Preventing medication errors in long-term care: Results and evaluation of a large scale web-based error reporting system. Quality & Safety in Health Care. 2007;16(4):297-302. https://doi.org/10.1136/qshc.2007.022483

상세보기
DeYoung JL, Vanderkooi ME, Barletta JF. Effect of bar-code-assisted medication administration on medication error rates in an adult medical intensive care unit. American Journal of Health-System Pharmacy. 2009;66(12):1110-1115. https://doi.org/10.2146/ajhp080355

상세보기
Poon EG, Keohane CA, Yoon CS, Ditmore M, Bane A, Levtzion-Korach O, et al. Effect of bar-code technology on the safety of medication administration. The New England Journal of Medicine. 2010;362(18):1698-1707. https://doi.org/10.1056/NEJMsa0907115

상세보기
Kim MS, Kim HH. Development of a medication error prevention system and its influence on patient safety culture and initiatives. Korean Journal of Adult Nursing 2015;27(1):1-10. https://doi.org/10.7475/kjan.2015.27.1.1

원문보기 상세보기
Taxis K, Barber N. Causes of intravenous medication errors: An ethnographic study. Quality & Safety in Health Care. 2003;12(5):343-347. https://doi.org/10.1136/qhc.12.5.343

상세보기
Lee HY. Associated factors with intention to reporting medication errors in general hospital nurses [master's thesis]. Gyeongsan: Daegu Catholic University; 2019. p. 1-47.
Shehata ZH, Sabri NA, Elmelegy AA. Descriptive analysis of medication errors reported to the Egyptian national online reporting system during six months. Journal of the American Medical Informatics Association. 2016;23(2):366-374. https://doi.org/10.1093/jamia/ocv096

상세보기
Oh CA, Yoon HS. Perception and experience of medication errors in nurses with less than one year job experience. Journal of Korean Academy Fundamentals of Nursing. 2007;14(1): 6-17.
Brady AM, Malone AM, Fleming S. A literature review of the individual and systems factors that contribute to medication errors in nursing practice. Journal of Nursing Management. 2009;17(6):679-697. https://doi.org/10.1111/j.1365-2834.2009.00995.x

상세보기
Brennan PA, Mitchell DA, Holmes S, Plint S, Parry D. Good people who try their best can have problems: Recognition of human factors and how to minimise error. British Journal of Oral and Maxillofacial Surgery. 2016;54(1):3-7. https://doi.org/10.1016/j.bjoms.2015.09.023

상세보기
You MA, Choe MH, Park GO, Kim SH, Son YJ. Perceptions regarding medication administration errors among hospital staff nurses of South Korea. International Journal for Quality in Health Care. 2015;27(4):276-283. https://doi.org/10.1093/intqhc/mzv036

상세보기
Ricci M, Panos AL, Lincoln J, Salerno TA, Warshauer L. Is aviation a good model to study human errors in health care? American Journal of Surgery. 2012;203(6):798-801. https://doi.org/10.1016/j.amjsurg.2011.06.010

상세보기
Santell JP, Hicks RW, McMeekin J, Cousins DD. Medication errors: Experience of the United States Pharmacopeia(USP) MEDMARK reporting system. Journal of Clinical Pharmacology. 2003;43(7):760-767. https://doi.org/10.1177/0091270003254831

상세보기
Mousavi M, Khalili H, Dashti-Khavidaki S. Errors in fluid therapy in medical wards. International Journal of Clinical Pharmacy. 2012;34:374-381. https://doi.org/10.1007/s11096-012-9620-8

상세보기
Kim YM, You MS, Cho YH, Park SH, Nam SN, Park MO, et al. Development and evaluation of a patient safety-focused in-service education program for surgical nurse. Journal of Korean Academy of Nursing Administration, 2010;16(2):152-161. https://doi.org/10.11111/jkana.2010.16.2.152

원문보기 상세보기
Goutos I, Cogswell LK, Giele H. Extravasation injuries: A review. Journal of Hand Surgery. 2014;39(8):808-818. https://doi.org/10.1177/1753193413511921

상세보기
Gorski LA. The 2016 infusion therapy standards of practice. Home Healthcare Now. 2017;35(1):10-18. https://doi.org/10.1097/NHH.0000000000000481

상세보기

내보내기 구분	파일저장 인쇄 메일전송
구성항목	기본정보 상세정보 관리번호, 논문명, 저널/프로시딩명, 저자 , 발행년, 권, 호, 시작페이지, 끝페이지, 발행기관 관리번호, 논문명, 대등논문명, 저자 , 저널/프로시딩명, 발행기관, 발행년, 발행언어, 권, 호, 시작페이지, 끝페이지, ISBN, ISSN, 주제분야, 키워드, 초록(한글), 초록(영문), 저자(소속기관)
저장형식	Text(ASCII format) Excel format RefWorks Direct Export RIS format (for Reference Manager, ProCite, EndNote), Scholar's Aids, Mendeley
메일정보	받는사람 (필수) @ 보내는사람 (선택) @ 제목 내용 KISTI 검색결과 이메일 서비스
안내	총 건의 자료가 검색되었습니다. 다운받으실 자료의 인덱스를 입력하세요. (1-10,000) 검색결과의 순서대로 최대 10,000건 까지 다운로드가 가능합니다. 데이타가 많을 경우 속도가 느려질 수 있습니다.(최대 2~3분 소요) 다운로드 파일은 UTF-8 형태로 저장됩니다. 파일의 내용이 제대로 보이지 않을실 때는 웹브라우저 상단의 보기 -> 인코딩 -> 자동선택 여부를 확인하십시오. ~ Text(ASCII format) Excel format

연합인증

환자안전사고 보고서를 통한 간호사 투약오류 분석
Analysis of Medication Errors of Nurses by Patient Safety Accident Reports 원문보기

Abstract ▼ AI-Helper

주제어

표/그림 (5)

표/그림 (5)

참고문헌 (30)

이 논문을 인용한 문헌

저자의 다른 논문 :

관련 콘텐츠

원문 보기

원문 URL 링크

오픈액세스(OA) 유형

이 논문과 함께 이용한 콘텐츠

AI-Helper ※ AI-Helper는 오픈소스 모델을 사용합니다.

선택된 텍스트

연합인증

환자안전사고 보고서를 통한 간호사 투약오류 분석 Analysis of Medication Errors of Nurses by Patient Safety Accident Reports 원문보기

Abstract ▼ AI-Helper

주제어

표/그림 (5) 모든 표/그림 보기

표/그림 (5) 슬라이드로 보기

참고문헌 (30)

이 논문을 인용한 문헌

저자의 다른 논문 :

구미지 (11)

관련 콘텐츠

원문 보기

원문 URL 링크

오픈액세스(OA) 유형

이 논문과 함께 이용한 콘텐츠

AI-Helper ※ AI-Helper는 오픈소스 모델을 사용합니다.

선택된 텍스트

환자안전사고 보고서를 통한 간호사 투약오류 분석
Analysis of Medication Errors of Nurses by Patient Safety Accident Reports 원문보기

표/그림 (5)

표/그림 (5)