解放军医院管理杂志
解放軍醫院管理雜誌
해방군의원관리잡지
Hospital Administration Journal of Chinese People’s Liberation Army
2015年
8期
782-785
,共4页
阚庭%李娟%师文文%储静
闞庭%李娟%師文文%儲靜
감정%리연%사문문%저정
Reason模型%护生%给药错误%不良事件%个案分析
Reason模型%護生%給藥錯誤%不良事件%箇案分析
Reason모형%호생%급약착오%불량사건%개안분석
Reason model%nursing student%error medication administration%adverse events%case study
由于护生在临床实习阶段缺乏经验，与护生相关的护理不良事件频频发生。 Reason提出的组织事故模型指出，在不良事件中，虽有一部分来自个人的疏忽或技术的不良，但是更大部分来自系统、程序、工作环境中的潜藏失误。本文运用Reason模型，对一例护生临床实习期间经历的护理给药错误不良事件进行分析，寻找出事件背后潜在的环境与组织漏洞，并提出相关对策，以避免类似事件再次发生。
由于護生在臨床實習階段缺乏經驗，與護生相關的護理不良事件頻頻髮生。 Reason提齣的組織事故模型指齣，在不良事件中，雖有一部分來自箇人的疏忽或技術的不良，但是更大部分來自繫統、程序、工作環境中的潛藏失誤。本文運用Reason模型，對一例護生臨床實習期間經歷的護理給藥錯誤不良事件進行分析，尋找齣事件揹後潛在的環境與組織漏洞，併提齣相關對策，以避免類似事件再次髮生。
유우호생재림상실습계단결핍경험，여호생상관적호리불량사건빈빈발생。 Reason제출적조직사고모형지출，재불량사건중，수유일부분래자개인적소홀혹기술적불량，단시경대부분래자계통、정서、공작배경중적잠장실오。본문운용Reason모형，대일례호생림상실습기간경력적호리급약착오불량사건진행분석，심조출사건배후잠재적배경여조직루동，병제출상관대책，이피면유사사건재차발생。
Nursing students are lack of experiences when they start clinical practice, which leads to the frequent occurrence of nursing adverse events related to nursing students.Reason had put forward Organizational Accident Model, which pointed out that the system or organizational failures underlying the errors account the most for an adverse event,though it is partly caused by personal negligence or unskillfulness.The article analyzed a case of error medication administration relevant to a nursing student by using Reason model, in order to find out the un-derlying environmental and organizational defects and propose some measures avoiding similar events.
