發(fā)布時間：2018-07-04 11:22

  本文選題：用藥失誤 + 新生兒重癥監(jiān)護(hù)�。� 參考：《北京協(xié)和醫(yī)學(xué)院》2015年博士論文

【摘要】：研究背景：新生兒重癥監(jiān)護(hù)室(Neonatal Intensive Care Unit, NICU)因其復(fù)雜的醫(yī)療環(huán)境被研究者界定為類似于核電、航空安全等級的系統(tǒng),需采取嚴(yán)格的方法監(jiān)測和控制系統(tǒng)安全,加強(qiáng)風(fēng)險管理預(yù)防失誤發(fā)生。由于患兒生理功能尚未發(fā)育完全和藥物治療的復(fù)雜性,使其更易暴露于用藥失誤的風(fēng)險中。護(hù)士作為藥物治療、用藥監(jiān)測及患者教育的直接執(zhí)行者,在患兒安全用藥每個環(huán)節(jié)中起著至關(guān)重要的作用。WHO倡導(dǎo)全球衛(wèi)生機(jī)構(gòu)學(xué)習(xí)其他高風(fēng)險工業(yè)領(lǐng)域經(jīng)驗(yàn),應(yīng)用風(fēng)險管理的理論和方法探尋系統(tǒng)中影響工作人員行為的風(fēng)險因素,促進(jìn)系統(tǒng)安全。目前尚缺乏對我國NICU護(hù)士用藥失誤行為產(chǎn)生影響的系統(tǒng)風(fēng)險因素進(jìn)行識別、分析與評價的研究。研究目的：(1)基于NICU用藥失誤數(shù)據(jù),對護(hù)士用藥失誤行為產(chǎn)生影響的系統(tǒng)風(fēng)險因素進(jìn)行識別與分析,確定NICU患兒用藥系統(tǒng)風(fēng)險因素及其與用藥失誤間的關(guān)聯(lián)度；(2)在風(fēng)險因素識別、分析基礎(chǔ)上,基于M-SHEL理論框架形成NICU患兒用藥系統(tǒng)風(fēng)險評價指標(biāo)體系,構(gòu)建風(fēng)險評價數(shù)學(xué)模型,結(jié)合實(shí)證進(jìn)行系統(tǒng)風(fēng)險綜合評價,并驗(yàn)證模型的有效性。研究方法：采用橫斷面研究,應(yīng)用美國藥物安全處方中心出版的ASSESS-ERRTM用藥失誤記錄單,收集2014年1月～12月北京市3家三甲醫(yī)院30名NICU護(hù)士自愿上報的用藥失誤(失誤／接近失誤)數(shù)據(jù),內(nèi)容包括基本資料,用藥失誤類型,患兒結(jié)局及失誤原因。基于上報數(shù)據(jù),描述NICU用藥系統(tǒng)失誤特征,以熟悉所評價的NICU用藥系統(tǒng)；通過事故樹分析法對失誤原因進(jìn)行定性分析,識別NICU用藥系統(tǒng)風(fēng)險因素,以確定風(fēng)險評價指標(biāo)；經(jīng)灰色關(guān)聯(lián)度分析法定量分析風(fēng)險因素與用藥失誤間的關(guān)聯(lián)度,以確立各風(fēng)險指標(biāo)客觀權(quán)重。基于M-SHEL理論框架,風(fēng)險評估小組采取頭腦風(fēng)暴法形成NICU患兒用藥系統(tǒng)風(fēng)險評價指標(biāo)體系�；诰W(wǎng)絡(luò)層次分析法構(gòu)建網(wǎng)絡(luò)結(jié)構(gòu),進(jìn)行組合賦權(quán),經(jīng)Super Decision軟件運(yùn)算建立風(fēng)險評價數(shù)學(xué)模型。選取非參與研究的某綜合醫(yī)院NICU進(jìn)行實(shí)證分析,由科室責(zé)任護(hù)士依據(jù)NICU患兒用藥系統(tǒng)風(fēng)險評價指標(biāo)實(shí)施風(fēng)險評價,基于模型結(jié)合模糊分析評價法,獲得患兒用藥系統(tǒng)風(fēng)險等級及風(fēng)險因素排序,與2014年1月～12月應(yīng)用ASSESS-ERRTM用藥失誤記錄單收集的患兒結(jié)局和失誤原因均值排序比對,驗(yàn)證該評價模型的有效性。結(jié)果：參與研究的NICU護(hù)士自愿上報156個用藥失誤。用藥失誤特征如下：以醫(yī)囑失誤為主(46.8%),出現(xiàn)時間集中在患兒進(jìn)入科室24小時以后(80.8%)多發(fā)生在白班(77.6%),藥物配置以科室自配為主(93.6%),藥物類型以抗菌藥(23.7%)和全胃腸道外營養(yǎng)(18.6%)為主,給藥途徑多以靜脈泵入(60.3%)。失誤發(fā)生到達(dá)患兒的結(jié)局以C級(即未對患兒造成傷害,27.7%)為主�；谑д`原因,識別出28個NICU系統(tǒng)風(fēng)險因素,與用藥失誤間的關(guān)聯(lián)度排序前3的是：工作人員安全防護(hù)不足(r=0.883)；失誤/預(yù)防的反饋缺乏(r-0.825)；新員工訓(xùn)練不足(r=0.814)。基于M-SHEL理論框架形成的NICU患兒用藥系統(tǒng)風(fēng)險評價指標(biāo)體系,包含6個一級風(fēng)險評價指標(biāo),28個二級風(fēng)險評價指標(biāo)。基于網(wǎng)絡(luò)層次分析法構(gòu)建的風(fēng)險評價數(shù)學(xué)模型中,軟件風(fēng)險和護(hù)士風(fēng)險權(quán)重值最高(W=0.222)。經(jīng)實(shí)證分析,綜合評價科室風(fēng)險等級為中等風(fēng)險,風(fēng)險因素排序由高到低的是：護(hù)士風(fēng)險管理軟件環(huán)境硬件其他人員；與38例用藥失誤數(shù)據(jù)中,患兒結(jié)局(最高為F級,即對患兒造成暫時性傷害)和失誤原因均值排序結(jié)果相一致。結(jié)論：本研究基于風(fēng)險管理的理論和方法,針對小樣本用藥失誤進(jìn)行分析,確定了28個與NICU用藥失誤相關(guān)的系統(tǒng)風(fēng)險因素,構(gòu)建出的NICU患兒用藥系統(tǒng)風(fēng)險評價模型,經(jīng)實(shí)證分析驗(yàn)證穩(wěn)定有效,客觀地評價出系統(tǒng)中的主要風(fēng)險因素及風(fēng)險等級,初步實(shí)現(xiàn)了對NICU患兒用藥系統(tǒng)風(fēng)險的綜合評價,但尚需更進(jìn)一步的驗(yàn)證。
[Abstract]:Background: Neonatal Intensive Care Unit (NICU) is defined as a system similar to nuclear power and aviation safety because of its complex medical environment. It is necessary to take a strict method to monitor and control the safety of the system and to strengthen the risk management and prevention errors. The physical function of the children has not been fully developed. The complexity of drug treatment makes it easier to expose to the risk of drug use errors. As a drug treatment, drug monitoring, and the direct executor of the patient's education, the nurse plays a vital role in every link of the safety medication of the child.WHO advocacy for the global health institutions to learn from other high-risk industrial experiences and to apply risk management. The theory and method explore the risk factors that affect the behavior of the staff in the system and promote the system safety. At present, there is still a lack of identification, analysis and evaluation of the systemic risk factors affecting the misbehavior of NICU nurses in our country. (1) based on the NICU error data, it has an impact on the misconduct of the nurses. The system risk factors are identified and analyzed to determine the risk factors of NICU children's drug use system and the correlation between the risk factors and the errors of drug use. (2) on the basis of risk factors identification and analysis, based on the M-SHEL theoretical framework, the risk evaluation index system of the drug system for NICU children is formed, the mathematical model of risk assessment is constructed, and the systematic wind is carried out in combination with the empirical analysis. Comprehensive assessment, and verify the validity of the model. Research methods: using the cross-sectional study, the ASSESS-ERRTM medication error record published by the American drug safety prescription center was used to collect data from 30 NICU nurses voluntarily reported by the 3 third class hospitals in Beijing from January 2014 to December. This data, the type of drug failure, the outcome of the children and the cause of the error. Based on the reported data, describe the NICU system error characteristics, to be familiar with the evaluation of the NICU drug system; through the accident tree analysis of the cause of the error qualitative analysis, identify the risk factors of the NICU drug system, to determine the risk evaluation index; through the grey correlation analysis Based on the M-SHEL theoretical framework, the risk assessment team adopted the brainstorming method to form the risk evaluation index system for the NICU children's drug use system based on the M-SHEL theoretical framework. Based on the network analytic hierarchy process, the network structure was constructed, and the Super Decision was soft and soft. A mathematical model of risk evaluation was established by part operation. An empirical analysis was carried out in a general hospital NICU, which was not involved in the study. The risk evaluation was carried out by the Department responsible nurses according to the risk evaluation index of the drug system of NICU children. Based on the model combined with the fuzzy analysis evaluation method, the risk ranking and risk factors of the children were ranked by the model combined with the method of fuzzy analysis, which was 1 in 2014. From month to December, the results of the evaluation model were verified by the comparison of the mean of the outcome and the cause of error collected by the ASSESS-ERRTM medication error record. Results: the NICU nurses participating in the study voluntarily reported 156 misses. The characteristics of the medication error were as follows: the medical advice error was mainly (46.8%), and the time of appearance was concentrated in the children's department. 24 hours later (80.8%) occurred in the white class (77.6%), the drug allocation was mainly in the section of the Department (93.6%), the drug type was mainly antibacterials (23.7%) and all gastrointestinal parenteral nutrition (18.6%), and the way of drug delivery was mostly intravenous (60.3%). The fault occurred to the child's knot at the C level (that is, no harm to children, 27.7%). 28 NICU system risk factors were identified. The first 3 of the degree of association between drug failure were: lack of staff safety protection (r=0.883); error / prevention feedback lack (r-0.825); lack of training for new employees (r=0.814). The risk assessment index system for the drug use system based on the M-SHEL theory framework contained 6 first level risks Evaluation index, 28 two level risk evaluation index. In the mathematical model of risk assessment based on the network analytic hierarchy process, the value of risk and nurse risk is the highest (W=0.222). Through empirical analysis, the comprehensive evaluation of the risk grade of the Department is medium risk, and the ranking of risk factors is high to low: the software environment of nurse risk management is the hardware. According to the theory and method of risk management, this study, based on the theory and method of risk management, analyzed the error of small sample drugs, and identified 28 systemic risk factors associated with the error of drug use in the 38 cases of NICU error. In order to evaluate the risk factors of the system, the risk assessment model of the drug system for NICU children was established, and the main risk factors and risk grades in the system were objectively evaluated. However, the comprehensive evaluation of the risk of drug use in NICU children was preliminarily realized, but further evidence was needed.
【學(xué)位授予單位】：北京協(xié)和醫(yī)學(xué)院
【學(xué)位級別】：博士
【學(xué)位授予年份】：2015
【分類號】：R473.72

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