用药接近失误事件上报平台的构建与应用研究

doi:10.3761/j.issn.0254-1769.2025.16.013

摘要/Abstract

摘要：

目的构建用药接近失误事件上报平台并评价其应用效果，以提高患者用药安全。方法基于文献检索、质性访谈、专家小组会议，构建用药接近失误事件上报平台，包括事件内容填写、事件风险分级、事件处置、统计分析4个模块。便利选取河南省某三级甲等医院儿科病区的50名护士作为应用对象，比较平台应用后（2023年3— 8月）及应用前（2022年9月—2023年2月）用药接近失误事件上报情况及填报时长、用药接近失误报告障碍量表评分、用药错误事件发生率。结果平台应用后的用药接近失误事件上报率高于平台应用前，且事件性质、发生环节的分布情况比较，差异具有统计学意义（P<0.05）。平台应用后，用药接近失误事件填报时长少于平台应用前，用药接近失误报告障碍量表评分低于平台应用前，差异具有统计学意义（P<0.001）。平台应用前后用药错误事件发生率比较，差异无统计学意义（P=0.241）。结论使用该平台有助于提升用药接近失误事件上报率，缩短填报时长，减少护士报告障碍。

关键词: 接近失误, 用药安全, 风险预警, 信息系统, 护理管理研究

Abstract:

Objective To develop a platform for reporting medication near miss events and evaluate its application effectiveness，aiming to enhance medication safety of patients. Methods Based on literature review，qualitative interviews，and expert group meetings，a medication near-miss event reporting platform was constructed，including 4 modules：event content filling，event risk grading，event handling，and statistical analysis. 50 nurses were conveniently selected from the pediatric ward of a tertiary grade A hospital in Henan Province as the application subjects. The reporting situation and filling duration of medication near miss events，the score of the Medication Near Miss Reporting Disorder Scale，and the incidence of medication near miss events were compared after the application of the platform（from March to August 2023） and before the application（from September 2022 to February 2023）. Results The reporting rate of medication near miss events after the application of the platform was higher than that before the application of the platform，and the comparison of the distribution of event nature and occurrence links showed statistically significant differences（P<0.05）. After the application of the platform，the reporting duration of medication near miss events was shorter than that before the application of the platform，and the score of the Medication Near Miss Reporting Disorder Scale was lower than that before the application of the platform. The differences were statistically significant（P<0.001）. There was no statistically significant difference in the incidence of medication near miss events before and after the application of the platform（P=0.241）. Conclusion Using this platform can help improve the reporting rate of medication near miss events，reduce the time taken to fill out reports，and minimize reporting barriers for nurses.

Key words: Near Miss, Medication Safety, Risk Warning, Information System, Nursing Administration Research

王芳, 杨晓果, 沈德新, 郑喜灿, 丁小勇, 江小萌, 皇甫佳欣, 瞿靖芮. 用药接近失误事件上报平台的构建与应用研究[J]. 中华护理杂志, 2025, 60(16): 2009-2015.

WANG Fang, YANG Xiaoguo, SHEN Dexin, ZHENG Xican, DING Xiaoyong, JIANG Xiaomeng, HUANGFU Jiaxin, QU Jingrui. Construction and application of a platform for reporting medication near-miss events[J]. Chinese Journal of Nursing, 2025, 60(16): 2009-2015.

图/表 2

参考文献 23

[1]	冯婷婷, 张欣, 谭玲玲, 等. 护理接近失误管理的研究进展[J]. 中华护理杂志, 2020, 55(1):153-157. DOI
	Feng TT, Zhang X, Tan LL, et al. A literature review of nurs-ing management for near miss[J]. Chin J Nurs, 2020, 55(1):153-157.
[2]	蔡喆燚, 邹婵, 黄璐, 等. 接近失误管理联合标准化沟通模式在肾内科危重患者院内转运中的应用[J]. 中华急危重症护理杂志, 2023, 4(4):293-298.
	Cai ZY, Zou C, Huang L, et al. Application of near miss mana-gement combined with standardized communication model in hospital transportation of critical patients in nephrology depart-ment[J]. Chin J Emerg Crit Care Nurs, 2023, 4(4):293-298.
[3]	Röhsig V, Lorenzini E, Mutlaq MFP, et al. Near-miss analysis in a large hospital in southern Brazil:a 5-year retrospective study[J]. Int J Risk Saf Med, 2020, 31(4):247-258.
[4]	陈颖颖, 丁姚, 郭亚威, 等. 儿科护士用药接近失误报告障碍现状及影响因素分析[J]. 中华现代护理杂志, 2021, 27(33):4541-4546.
	Chen YY, Ding Y, Guo YW, et al. Status quo and influencing factors of medication near-miss reporting barriers for pediatric nurses[J]. Chin J Mod Nurs, 2021, 27(33):4541-4546.
[5]	Sinclair JE, Austin MA, Bourque C, et al. Barriers to self-repor-ting patient safety incidents by paramedics:a mixed methods study[J]. Prehosp Emerg Care, 2018, 22(6):762-772. DOI PMID
[6]	Yang Y, Liu HP, Sherwood GD. Second-order problem solving:nurses’ perspectives on learning from near misses[J]. Int J Nurs Sci, 2021, 8(4):444-452.
[7]	徐冬梅, 顾则娟, 张新月, 等. 基于护理信息系统的接近失误事件及护理不良事件发生现状的纵向研究[J]. 护理研究, 2021, 35(13):2295-2298.
	Xu DM, Gu ZJ, Zhang XY, et al. Occurrence status of near-miss events and adverse events based on nursing information system:a longitudinal study[J]. Chin Nurs Res, 2021, 35(13):2295-2298.
[8]	周淑芬, 刘翠青, 谢翠媚, 等. 护理不良事件与安全隐患上报双轨化管理的实施效果[J]. 护理学报, 2018, 25(5):24-26.
	Zhou SF, Liu CQ, Xie CM, et al. Implementation effect of dual-track management for reporting nursing adverse events and potential safety hazards[J]. J Nurs(China), 2018, 25(5):24-26.
[9]	于冉, 马昕璇, 甘青文, 等. 护士经历接近失误事件质性研究的Meta整合[J]. 中华急危重症护理杂志, 2024, 5(9):806-811.
	Yu R, Ma XX, Gan QW, et al. Nurses’ experiences of near-miss events:a qualitative meta-synthesis[J]. Chin J Emerg Crit Care Nurs, 2024, 5(9):806-811.
[10]	王文丽, 张艳丽, 王超滨, 等. 我国医疗质量安全不良事件数据分析[J]. 中国医院, 2025, 29(1):25-28.
	Wang WL, Zhang YL, Wang CB, et al. Data analysis of adverse events in medical quality and safety in China[J]. Chin Hosp, 2025, 29(1):25-28.
[11]	Shaw KN, Lillis KA, Ruddy RM, et al. Reported medication events in a paediatric emergency research network:sharing to improve patient safety[J]. Emerg Med J, 2013, 30(10):815-819.
[12]	Cifra CL, Jones KL, Ascenzi J, et al. The morbidity and morta-lity conference as an adverse event surveillance tool in a pae-diatric intensive care unit[J]. BMJ Qual Saf, 2014, 23(11):930-938.
[13]	房金霞. 基于社会生态系统理论的护士用药接近失误报告意向及其影响因素研究[D]. 济南: 山东大学, 2022.
	Fang JX. Study on nurses’ intention to report medication approaching errors and its influencing factors based on social ecosystem theory[D]. Jinan: Shandong University, 2022.
[14]	彭骞, 蒋志平, 何莉梅, 等. 我院门诊药房相似药品差错及接近失误的监控及质量改进[J]. 儿科药学杂志, 2016, 22(12):40-42.
	Peng Q, Jiang ZP, He LM, et al. Quality improvement and monitoring of similar medication errors and near misses in outpatient pharmacy[J]. J Pediatr Pharm, 2016, 22(12):40-42.
[15]	朱建妹, 梁志金, 万玫, 等. 护理接近失误原因分析及预防研究进展[J]. 护理学杂志, 2021, 36(15):102-105.
	Zhu JM, Liang ZJ, Wan M, et al. Causal analysis and preven-tion of near miss incidents in nursing:a review[J]. J Nurs Sci, 2021, 36(15):102-105.
[16]	王海燕, 王美兰. 医疗失效模式与效应分析在临床护理风险管理中的研究现状[J]. 护理学杂志, 2015, 30(19):107-109.
	Wang HY, Wang ML. Research progress of failure mode and effect analysis in risk management of clinical nursing[J]. J Nurs Sci, 2015, 30(19):107-109.
[17]	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
	Li HY, Wang H, Bian SQ, et al. Medical failure mode and effect analysis in pediatric intravenous drug admixture[J]. J Nurs (China), 2020, 27(20):12-16.
[18]	马继永, 张锐利. 应用失效模式与效应分析方法建立医院药房质量风险管理体系[J]. 现代医院管理, 2020, 18(3):50-55.
	Ma JY, Zhang RL. Establishment of quality risk management system in hospital pharmacy with failure mode and effect analysis[J]. Mod Hosp Manag, 2020, 18(3):50-55.
[19]	于淼, 王建辉. 用药接近失误报告障碍量表的修订及信度效度检验[J]. 中国护理管理, 2020, 20(1):22-25.
	Yu M, Wang JH. Revision,validity and reliability of Chinese version of the Barriers to Near-Miss Reporting Scale[J]. Chin Nurs Manag, 2020, 20(1):22-25.
[20]	张欣, 韩冬韧, 冯淑菊, 等. NICU用药接近失误相关系统风险因素分析[J]. 中国护理管理, 2017, 17(8):1087-1091.
	Zhang X, Han DR, Feng SJ, et al. The analysis of risk factors of medication near misses in NICU work system[J]. Chin Nurs Manag, 2017, 17(8):1087-1091.
[21]	于淼, 王建辉, 刘学明, 等. 护士给药接近失误报告障碍的影响因素分析[J]. 中华护理杂志, 2020, 55(9):1304-1309. DOI
	Yu M, Wang JH, Liu XM, et al. The route cause analysis of nurse medication near-miss reporting barriers[J]. Chin J Nurs, 2020, 55(9):1304-1309. DOI
[22]	Yung HP, Yu S, Chu C, et al. Nurses’ attitudes and perceived barriers to the reporting of medication administration errors[J]. J Nurs Manag, 2016, 24(5):580-588.
[23]	谭然, 曹英娟, 夏京花, 等. 护士发生用药错误心理体验质性研究的系统评价[J]. 中华护理杂志, 2020, 55(5):740-746. DOI
	Tan R, Cao YJ, Xia JH, et al. Nurses’ psychological experience of medication errors:a systematic review of qualitative studies[J]. Chin J Nurs, 2020, 55(5):740-746. DOI