基于 ICPS 分类法框架的护理相关药物事件的影响因素分析

目的：识别护理相关药物事件的影响因素，提出有效的预控措施。方法随机抽取上海市15所三级医疗机构，对选取的医疗机构上报至上海市护理质量控制中心的1343例“药物事件”案例进行研究，运用内容分析法，以WHO患者安全国际分类法（ ICPS）中的“影响因素”水平为类目构建的研究工具对案例进行影响因素分析。结果事件发生时间分布中，发生于早班（8：00-16：00）的事件最多，占62．84％，这显然与早班治疗性护理最多最繁忙有关。年龄分布中，护理相关“药物事件”所累及的患者高龄者占绝对优势，70岁以上的患者，占32．45％，由此提示高龄患者自理能力、沟通能力薄弱，是用药差错的高危人群。 ICPS中将患者安全事件所致患者结果分为5个水平，即无、轻微、中度、重度、死亡。1343例“药物事件”中，无伤害占91．88％，轻微伤害占3．35％，中度伤害占2．76％，重度伤害占2．01％，无死亡案例发生。1343例护理相关“药物事件”中出现影响因素频次3185，发生频次从高到低依次为常规性违规、技术型错误中“疏忽”、技术型错误中的“过失”、规则型错误中“错误地使用了良好的规则”、知识型错误、沟通因素、错觉相关。结论应用患者安全国际分类法影响因素类目有利于护理管理者从“人因失误”角度甄别系统和流程缺陷，提升患者安全的管理水平。

Analysis of the influencing factors of nursing related medication errors based on the conceptual framework of international classification of patient safety

Objective To identify the influencing factors of nursing related medication errors , and put forward the effective prevention and control measures .Methods One thousand three hundred and forty-three cases with medication errors from 15 tertiary hospitals in Shanghai Nursing Quality Control Center were chosen . The influencing factors were analyzed by the research tools which were constructed by the level of influencing factors depending on the international classification of patient safety （ ICPS ） through the method of content analysis.Results The occurrences of medication errors were most frequent （62.84%） in the early morning （8：00-16：00）, and were related to the most therapeutic nursing .The nursing related medication errors happened frequently in elderly patients with more than 70 years old （32.45%）, and which suggested that the abilities of self-care and communication in elderly patients were weak , and the elderly patients were the highest risk of medication errors .The results of safety events of patients in the ICPS were divided into 5 levels including the no, mild, moderate, severe, death.The percent of medication errors including the no , mild, moderate, severe, death in 1 343 cases were respectively 91.88%, 3.35%, 2.76%, 2.01%, 0%.The frequencies of influencing factors of nursing related medication errors in 1 343 cases were 3 185, and the frequencies from high to low were respectively routine violations ,“negligence” and “fault” in the technical mistakes ,“misapplication of good rules” in the error of rule, knowledge-based mistake, communication and illusion.Conclusions Application of the influencing factor of ICPS is helpful to discriminate the system and process defect from the perspective of human error in the nursing managers , and can improve the level of management of patient safety .