新生儿重症监护室患儿用药系统风险评价模型构建研究

发布时间：2018-07-04 11:22

本文选题：用药失误 + 新生儿重症监护　；参考：《北京协和医学院》2015年博士论文

【摘要】：研究背景：新生儿重症监护室(Neonatal Intensive Care Unit, NICU)因其复杂的医疗环境被研究者界定为类似于核电、航空安全等级的系统,需采取严格的方法监测和控制系统安全,加强风险管理预防失误发生。由于患儿生理功能尚未发育完全和药物治疗的复杂性,使其更易暴露于用药失误的风险中。护士作为药物治疗、用药监测及患者教育的直接执行者,在患儿安全用药每个环节中起着至关重要的作用。WHO倡导全球卫生机构学习其他高风险工业领域经验,应用风险管理的理论和方法探寻系统中影响工作人员行为的风险因素,促进系统安全。目前尚缺乏对我国NICU护士用药失误行为产生影响的系统风险因素进行识别、分析与评价的研究。研究目的：(1)基于NICU用药失误数据,对护士用药失误行为产生影响的系统风险因素进行识别与分析,确定NICU患儿用药系统风险因素及其与用药失误间的关联度；(2)在风险因素识别、分析基础上,基于M-SHEL理论框架形成NICU患儿用药系统风险评价指标体系,构建风险评价数学模型,结合实证进行系统风险综合评价,并验证模型的有效性。研究方法：采用横断面研究,应用美国药物安全处方中心出版的ASSESS-ERRTM用药失误记录单,收集2014年1月～12月北京市3家三甲医院30名NICU护士自愿上报的用药失误(失误／接近失误)数据,内容包括基本资料,用药失误类型,患儿结局及失误原因。基于上报数据,描述NICU用药系统失误特征,以熟悉所评价的NICU用药系统；通过事故树分析法对失误原因进行定性分析,识别NICU用药系统风险因素,以确定风险评价指标；经灰色关联度分析法定量分析风险因素与用药失误间的关联度,以确立各风险指标客观权重。基于M-SHEL理论框架,风险评估小组采取头脑风暴法形成NICU患儿用药系统风险评价指标体系。基于网络层次分析法构建网络结构,进行组合赋权,经Super Decision软件运算建立风险评价数学模型。选取非参与研究的某综合医院NICU进行实证分析,由科室责任护士依据NICU患儿用药系统风险评价指标实施风险评价,基于模型结合模糊分析评价法,获得患儿用药系统风险等级及风险因素排序,与2014年1月～12月应用ASSESS-ERRTM用药失误记录单收集的患儿结局和失误原因均值排序比对,验证该评价模型的有效性。结果：参与研究的NICU护士自愿上报156个用药失误。用药失误特征如下：以医嘱失误为主(46.8%),出现时间集中在患儿进入科室24小时以后(80.8%)多发生在白班(77.6%),药物配置以科室自配为主(93.6%),药物类型以抗菌药(23.7%)和全胃肠道外营养(18.6%)为主,给药途径多以静脉泵入(60.3%)。失误发生到达患儿的结局以C级(即未对患儿造成伤害,27.7%)为主。基于失误原因,识别出28个NICU系统风险因素,与用药失误间的关联度排序前3的是：工作人员安全防护不足(r=0.883)；失误/预防的反馈缺乏(r-0.825)；新员工训练不足(r=0.814)。基于M-SHEL理论框架形成的NICU患儿用药系统风险评价指标体系,包含6个一级风险评价指标,28个二级风险评价指标。基于网络层次分析法构建的风险评价数学模型中,软件风险和护士风险权重值最高(W=0.222)。经实证分析,综合评价科室风险等级为中等风险,风险因素排序由高到低的是：护士风险管理软件环境硬件其他人员；与38例用药失误数据中,患儿结局(最高为F级,即对患儿造成暂时性伤害)和失误原因均值排序结果相一致。结论：本研究基于风险管理的理论和方法,针对小样本用药失误进行分析,确定了28个与NICU用药失误相关的系统风险因素,构建出的NICU患儿用药系统风险评价模型,经实证分析验证稳定有效,客观地评价出系统中的主要风险因素及风险等级,初步实现了对NICU患儿用药系统风险的综合评价,但尚需更进一步的验证。
[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.
【学位授予单位】：北京协和医学院
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R473.72

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