031-040 原著03 濱田 責 - janap.umin.ac.jp

1 The Journal of the japan Academy of Nursing Administration and Policies Vol 9, No 2, pp 31 40, 2006.. Study of Con rmation Errors for Internal Use by Nurses 1 2 3 . 3 4 . Yasuyo Hamada Daisuke Taguchi Mieko Sakai Kanako Murata Sawako Kawamura Key words medication errors, con rmation errors, risk factors . Abstract Medication errors for internal use are one of the most serious issues of all malpractice cases by nurses. The greatest problem is involved with the failure of con rmation. So far, there are few reports which analyzed the factors related to the causes or the stages of malpractice occurrence.

2 In this study, con rmation errors identi ed from the incidents reported in the government publi- cation were categorized according to our own algorithm and analyzed to determine the contribut- ing factors. The ndings were : Con rmation errors, which comprised 70% of all errors, occurred at the stages of con rming the acceptance of doctor's order, of checking the compatibility of nurse's planning with doctor's order, and of the compatibility of nursing action just prior to actual provi- sion with the doctor's order. The con rmation errors involved with the nurse's acceptance of orders, or with the nurse's actions as indicated above, in addition to con rmation involved with the nurse's evaluation of the validity of orders were categorized by ve items of causal factors.

3 A signi cant difference was observed between the distribution of the related causal factors and that of the entire items of con rmation. Preventive measures should be programmed at each con rmation process.. 70 .. 5 5 . 2005 6 28 2005 12 5 . 1 Graduate School of Human Sciences, Waseda University 2 Nursing Department, Keio University Hospital 3 Faculty of Health Sciences, Tokyo Metropolitan University 4 Graduate School of Health Sciences, Aomori University of Health and Welfare Vol 9, No 2, 2006 31.. HP 2001 . 13 10 .. 4 7 2002 4 1 . 2003 3 31 3,724 . HP 2001 .. 1 . 2.. 2002 2001 . 1 .. web.

4 1999 . 2004 . 17 2002 . 2004 2002 2002 . 2002 2002 2001 . 2002 2003 2003 . 2002 2000 2000 . 2001 2003 2002 .. 2002 2001 . 2000 McCloskey et al. 2002 .. 2000 .. 10 .. 1 2 . 10 .. 1.. 32 Vol 9, No 2, 2006.. 1 . 2 . 3,724 . 483 483 4.. 256 . 26 230 .. 3.. 1.. 230 249 .. 1 3 .. 249 .. 2 .. SHEL HP 1999 1 .. Soft-ware .. Hard-ware . Environment . Live- 45 249 . ware Live'-ware 5 . MS 2 10 18. 2 . 3 5 2 2 1 .. 2 . for . 15 . Windows p .. Vol 9, No 2, 2006 33.. NO NS .. YES. NO. 1 .. YES. 2.. NO .. YES. NO.. YES. 3.. NO.. YES.. NO.. YES.. NS .. NO.. YES .. NO.. YES.. NO .. YES.. NO.. YES.. Yes 1.

5 No 2 .. 3 . 2 . 34 Vol 9, No 2, 2006. 80 SHEL 5 . 60. 70 72 142 . 60. 45.. 55 .. 50 . 40 23 20 120 . 15 558 . 30 10.. 20 3 . 10 140 .. 0. 0 100 200 300 400 500 600.. 3 4 5 .. 3 . 7 .. 72 . 20 . MS 1 60 mg 3 . 1 10 mg 2 . 10 mg 1 . 4 3 .. 23 . 8 .. 10 .. 5 .. 2.. 249 1,015 .. 60 SHEL 5 .. 142 .. MS 2 55 120 .. 2 558 . 140 . 4 . 6 . 3.. 3 .. 5 5 . A 1 . 5 . B 5 c2 . Vol 9, No 2, 2006 35. 1 1 230 .. Soft-ware 29 7 51 16 18 4 13 4 142 . 16 2 16 12 12 3 6 4 71 . 0 1 6 1 1 0 0 0 9 . 9 3 19 0 0 0 1 0 32 . 4 1 10 3 5 1 6 0 30 . Hard-ware 3 3 26 3 17 0 3 0 55 . 0 0 1 0 3 0 0 0 4 . 36 Vol 9, No 2, 2006.

6 0 0 0 1 3 0 0 0 4 .. 3 3 25 2 11 0 3 0 47 . Environment 15 4 29 9 58 0 2 3 120 . 5 0 6 0 9 0 0 0 20 . 0 0 1 0 2 0 0 0 3 . 9 4 15 8 25 0 1 2 64 . 0 0 1 0 3 0 0 0 4 . 1 0 6 1 19 0 1 1 29 . Live-ware 102 37 171 44 139 6 37 22 558 . 2 28 7 25 3 7 0 2 3 75 . 3 13 17 73 14 50 3 15 8 190 . 4 0 0 2 0 2 0 1 0 5 . 5 3 2 9 3 20 0 0 0 37 . 58 11 62 24 60 3 19 11 251 . Live'-ware 36 19 34 9 14 9 11 8 140 . 1 1 6 0 0 0 0 0 8 . 9 0 11 1 9 2 1 1 34 .. 0 0 0 0 0 0 3 0 3 . 7 15 11 3 0 0 0 0 36 . 0 0 0 0 1 0 0 0 1 . 19 3 6 3 4 2 2 1 40 . 0 0 0 2 0 5 5 6 18 . 185 70 311 81 246 19 66 37 1,015 .. 1 5 p p 2 .. 3.

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8 3 70 .. 2 5 .. Vol 9, No 2, 2006 39. 32 94 96 . 2003 . 5 5 .. 34 80 82 . Kohn & Corrigan, . 2000 TO ERR IS. HUMAN . 79 . 2001 . html McCloskey, & Bulechek, . 2002 NIC 3 664 668 .. 2003 . 2001 . 34 85 87 . 26 243 249 2000 . 2002 42 . 2003 . 15 83 92 . 2004 28 1 59 67 . 1999 . 41 1 . 47 53 . 2000 Evidence-Based Nursing 52 2 22 26 2002 . 2000 .. 14 1 4 . 31 63 65 2000 . 2002 . 12 . 33 5 21 . 287 289 2004 . 2002 . 33 12 14 2002 html 33 2002 . 3 5 SHEL . 2001 33 263 265 . 12 1995 13 . 9 30 . 2002 2002 .. 3 33 . 119 121 33 9 11 . 2002 2002 .. 33 278 33 . 280 42 44 . 2001 2000 .. 40 Vol 9, No 2, 2006.