doi:10.3761/j.issn.0254-1769.2020.01.027

Abstract

Key words: Near Miss, Safety Management, Nursing Administration Research, Review

摘要：

该文对接近失误在护理领域的概念与内涵、接近失误的管理进行综述,其中接近失误的管理包括接近失误的识别与上报、接近失误的分级、接近失误的分析、接近失误改善措施的形成、实施、效果评价及分享,旨在为推进患者安全工作可持续健康发展,运用对患者无损害的前瞻性接近失误风险管理主动进行风险防范提供参考。

关键词: 接近失误, 安全管理, 护理管理研究, 综述

冯婷婷, 张欣, 谭玲玲, 刘华平. 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.

References 38

[1]	张海燕, 尚文涵, 简伟研 , 等. 护士执业环境对患者安全的影响[J]. 中国护理管理, 2018,18(10):1307-1310.
[2]	World Health Organization. Leadership competencies on patient safety and quality of care（DRAFT）[EB/OL].( 2014-03)[2019-05-21]. https://www.who.int/servicedeliverysafety/areas/health-servi-ce-delivery-for-leaders.pdf?ua=1 .
[3]	陈静, 岳丽青, 曹扬 , 等. 有源医疗器械相关不良事件的发生原因分析及建议[J]. 中华护理杂志, 2018,53(11):1363-1366.
[4]	Ghebreyesus TA . 6th annual world patient safety,science & technology summit[EB/OL].( 2018-02-23)[2019-04-10]. http://www.who.int/dg/speeches/2018/patient-safety-summit/en/ .
[5]	刘华平 . 对开展接近失误管理以提高患者安全的思考[J]. 上海护理, 2018,18(3):5-9.
[6]	Speroni KG, Fisher J, Dennis M , et al. What causes near-misses and how are they mitigated?[J]. Nursing, 2013,43(4):19-24.
[7]	中国医院协会. 三级综合医院评审标准实施指南:2011年版[M]. 北京: 人民卫生出版社, 2011.
[8]	International Joint Commission. Joint Commission international accreditation standards for hospitals,6th edition[EB/OL].( 2018-01-08)[2019-04-05]. https://www.jointcommissioninternational.org/jci-accreditation-standards-for-hospitals-6th-edition/ .
[9]	Claffey C . Near-miss medication errors provide a wake-up call[J]. Nursing, 2018,48(1):53-55.
[10]	中国医院协会. 中国医院协会患者安全目标（2017版）[EB/OL].(2016-11-26)[2019-04-05]. http://www.sqsyy.com/sfyy/wjtz/2016-11-26/3052.html.
[11]	中国医院协会. 中国医院质量安全管理: 第4部分医疗管理:T/CHAS 10-4-6-2018[S]. 北京:中国医院协会, 2018.
[12]	邓小鹏, 周志鹏, 李启明 , 等. 地铁工程Near-miss知识库构建[J]. 东南大学学报(自然科学版), 2010,40(5):1103-1109.
[13]	Go U . Near-miss:a tool for integrated safety,health,environme-ntal and security management[D]. Philadelphia:University of Pennsylvania, 2002.
[14]	Aspden P, Corrigan J, Wolcott J , et al. Patient safety:achieving a new standard for care[M]. Washington DC: National Acade-mies Press, 2004.
[15]	Aspden P, Wolcott J, Bootman J , et al. Preventing medication errors:quality chasm series[M]. Washington,DC: National Aca-demies Press, 2007.
[16]	石贞仙, 杜巧, 徐建萍 , 等. 未遂事件上报激励机制在护理安全管理中的应用[J]. 中国护理管理, 2011,11(9):53-56.
[17]	吴惠平, 宋晨 . 临床护理异常事件案例分析与预防[M]. 北京: 人民卫生出版社, 2014.
[18]	Hamilton EC, Pham DH, Minzenmayer AN , et al. Are we missing the near misses in the OR?-underreporting of safety incidents in pediatric surgery[J]. J Surg Res, 2018,221:336-342.
[19]	Partnership NP . Preventing medication errors:a $21 billion opportunity[EB/OL].( 2010-12)[2019-04-10]. https://psnet.ahrq.gov/resources/resource/20529 .
[20]	Vrbnjak D, Denieffe S, O’Gorman C, , et al. Barriers to reporting medication errors and near misses among nurses:a systematic review[J]. Int J Nurs Stud, 2016,63:162-178.
[21]	Kessels-Habraken M, van der Schaaf T, De Jonge J , et al. De-fining near misses:towards a sharpened definition based on empirical data about error handling processes[J]. Soc Sci Med, 2010,70(9):1301-1308.
[22]	林辛霞, 许素芃, 刘晓为 , 等. 护理不良事件的分类分级报告处理[J]. 护理研究, 2012,26(19):1802-1803.
[23]	严莉, 肖明朝, 贺世春 , 等. 基于SRK模型的护理人为差错类型分析及管理对策[J]. 护理学杂志, 2018,33(2):65-68.
[24]	Mitchell I, Schuster A, Smith K , et al. Patient safety incident reporting:a qualitative study of thoughts and perceptions of experts 15 years after ‘To Err is Human’[J]. BMJ Qual Saf, 2016,25(2):92-99.
[25]	Gnoni MG, Saleh JH . Near-miss management systems and observability-in-depth:handling safety incidents and accident precursors in light of safety principles[J]. Saf Sci, 2017,91:154-167.
[26]	Kodama S, Kanda K . Nurse risk managers’ criteria for dealing with near-miss events[J]. Biosci Trends, 2010,4(5):231-238.
[27]	杨依 . 基于接近失误的护士二级解决问题行为意向模型研究[D]. 北京:北京协和医学院, 2017.
[28]	张宗久 . 中国医院评审实务[M]. 北京: 人民军医出版社, 2013.
[29]	Gnoni MG, Lettera G . Near-miss management systems:a metho-dological comparison[J]. J Loss Prev Process Ind, 2012,25(3):609-616.
[30]	冯雷, 吴大军 . 航天器AIT未遂事件管理系统设计及数据分析[J]. 中国安全生产科学技术, 2017,13(8):102-107.
[31]	National Aeronautics and Space Administration. NASA accident precursor analysis handbook（Version 1.0）[EB/OL].( 2011-12)[2019-04-10]. https://core.ac.uk/display/10566585
[32]	Malicki J, Bly R, Bulot M , et al. Patient safety in external beam radiotherapy,results of the ACCIRAD project:Recommendations for radiotherapy institutions and national authorities on assessing risks and analysing adverse error-events and near misses[J]. Radiother Oncol, 2018,127(2):164-170.
[33]	Gwen Sherwood, Jane Barnsteiner . 护理质量与安全:改善结局的核心能力(翻译版)[M]. 北京: 人民卫生出版社, 2018.
[34]	陈骥 . 基于平衡计分卡和数据包络法的某钢铁企业安全绩效研究[D]. 衡阳:南华大学, 2016.
[35]	蔡月茹 . 基于平衡计分卡的民航安全信息工作绩效管理研究[D]. 天津:中国民航大学, 2016.
[36]	龙艳芳, 李映兰, 郭燕红 . 我国护理不良事件报告现况调查及分析[J]. 中国护理管理, 2011,11(5):16-20.
[37]	徐晶, 陈荣凤, 郑微艳 , 等. 医疗不良事件中第二受害者及其组织支持的研究现状与启示[J]. 中华护理杂志, 2017,52(4):485-488.
[38]	臧娴, 白姣姣 . 信息技术在护理不良事件管理中的应用进展[J]. 中华护理教育, 2017,14(1):29-32.

护理接近失误管理的研究进展

RichHTML

PDF

Knowledge

Abstract

Cite this article

share this article

References 38

Related Articles 15

Recommended Articles

Metrics

[1]	LIU Mengyuan, TIAN Lingyun, JIANG Jing, FENG Xinyu, LI Weijuan, LUO Hui, LI Yinglan. Ethical conflicts in interprofessional collaboration among nurses：a scoping review [J]. Chinese Journal of Nursing, 2024, 59(9): 1138-1144.
[2]	CUI Yishuang, HE Xifei, WANG Zhaozhao, CHENG Jie, YANG Weimei, LU Lijuan. Shared decision making in acute coronary syndromes：a scoping review [J]. Chinese Journal of Nursing, 2024, 59(9): 1145-1152.
[3]	ZHANG Xiaoyan, LI Xuejing, YANG Dan, MENG Meiqi, HAO Yufang. Intervention strategies for reducing sedentary behavior among older adults：a scoping review [J]. Chinese Journal of Nursing, 2024, 59(8): 1012-1020.
[4]	YU Liangmeng, YU Xiaoling, LI Jiamei, RUAN Xiaofen. Application progress of evidence mapping in nursing field [J]. Chinese Journal of Nursing, 2024, 59(8): 1021-1025.
[5]	FANG Yu, HAO Yuanyuan, ZHANG Chen, DONG Ying, WU Yingxin, JIANG Guichun. Research progress and nursing inspiration on decision fatigue in cancer patients [J]. Chinese Journal of Nursing, 2024, 59(8): 941-946.
[6]	SONG Xiaoan, LU Xingquan, MA Jing, WANG Yafan, WANG Xiaohua, REN Hong, GAO Jun. Study on the development and application of an evaluation management information system for new nurses [J]. Chinese Journal of Nursing, 2024, 59(8): 974-979.
[7]	DUAN Siyu, HOU Ming, DING Min, SUN Yao, LI Ping. The current status and influencing factors of thriving at work among junior nurses [J]. Chinese Journal of Nursing, 2024, 59(7): 848-853.
[8]	YE Lei, XIA Guanghui, CHEN Fangmei, TIAN Yuyan, QI Wei. A scoping review of virtual reality on the effects on patients of cancer-related cognitive impairment [J]. Chinese Journal of Nursing, 2024, 59(7): 882-889.
[9]	XIONG Tao, TAN Xuemei, LUO Jing, LI Yang, ZHENG Yuxi, LI Fengling, WEI Xuemei, CUI Lijun, LUO Lanjun. Research progress on rehabilitation motivation assessment tools for stroke patients [J]. Chinese Journal of Nursing, 2024, 59(7): 890-896.
[10]	WANG Xuan, WEN Xianxiu, GOU Li, ZHOU Lijuan, CHEN Fuli, WU Haiyan, WANG Liang. The cardiac rehabilitation adherence assessment tools：a systematic review of psychometric properties [J]. Chinese Journal of Nursing, 2024, 59(6): 736-743.
[11]	YAN Yu, GONG Shu, DUAN Difei, MA Dengyan. Application and progress of knowledge graphs in dietary management of patients with chronic diseases [J]. Chinese Journal of Nursing, 2024, 59(6): 753-757.
[12]	DENG Yifan, WANG Jianning, PENG Mengting, HONG Du. Decision aids for care decision making in dementia patients：a scoping review [J]. Chinese Journal of Nursing, 2024, 59(6): 758-763.
[13]	ZHANG Miaomiao, ZHANG Li, YAN Rong, DING Min, MENG Xiangmin, XU Ping. Application progress of online grief counseling in palliative care [J]. Chinese Journal of Nursing, 2024, 59(5): 556-561.
[14]	SHENG Zhiqiong, YAN Xingyu, LIU Yuwen, LI Shuhuan, DING Yanjie, CHEN Shanshan, YE Minghui, SUN Caixia. The level and influencing factors of spare time planning of clinical nurses [J]. Chinese Journal of Nursing, 2024, 59(5): 588-593.
[15]	XU Rongjing, HE Xuyan, JIA Shoumei. A scoping review of kinesiophobia research in elderly orthopedic postoperative patients [J]. Chinese Journal of Nursing, 2024, 59(5): 626-633.