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目的:描述NICU护士自愿上报用药接近失误的特征,对相关系统因素进行风险识别与分析。方法:采用美国药物安全处方中心的ASSESS-ERRTM用药失误记录单(2006),收集2014年1月至2015年12月北京市4家医院42名NICU护士自愿上报的用药接近失误,应用灰色关联度分析法进行相关原因分析。结果:护士自愿上报134例用药接近失误,以医嘱失误为主(58.2%),风险最高指标是开立医嘱阶段的药物关键信息失误(ξ_2=0.425),通过关联度(r)值对不同用药阶段风险程度进行排序:备药>开立医嘱>配药>给药>监测/教育。结论:通过分析NICU用药接近失误产生的系统风险因素,利于护士有针对性地采取风险管理策略,以提升患儿的用药安全。
OBJECTIVE: To describe the characteristics of NICU nurses reporting voluntarily drug failures and identifying and analyzing the related system factors. METHODS: The ASSESS-ERRTM Medication Error Record (2006) of the US Drug Safety Prescription Center was used to collect the voluntary medication reported by 42 NICU nurses in 4 hospitals in Beijing from January 2014 to December 2015. The gray incidence Analysis of the relevant reasons. Results: The nurses voluntarily reported 134 cases of medication errors and the majority of them failed the medical orders (58.2%). The highest risk index was the key information error (ξ_2 = 0.425) for the medication at the stage of doctor’s advice. Sort the degree of risk stages: Preparing medicine> Opening a doctor’s order> Pharmaceuticals> Drugs> Monitoring / Education. Conclusion: By analyzing the systematic risk factors resulting from the NICU medication approach error, nurses can take a targeted risk management strategy to improve their drug safety.