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首页> 外文期刊>The joint commission journal on quality and patient safety >Shaping Systems for Better Behavioral Choices: Lessons Learned from a Fatal Medication Error
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Shaping Systems for Better Behavioral Choices: Lessons Learned from a Fatal Medication Error

机译：塑造系统以获得更好的行为选择：从致命用药错误中吸取的教训

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Background: In July 2006, a 16-year-old patient came to the hospital to deliver her baby. During the process of her care, an infusion intended exclusively for the epidural route was connected to the patient's peripheral intravenous line and infused by pump. The patient experienced cardiovascular collapse. A cesarean section resulted in the delivery of a healthy infant, but the medical team was unable to resuscitate the mother. The media attention surrounding the error accelerated through the national provider and safety community when the nurse was charged with a criminal offense. These events set in motion intense internal and external scrutiny of the hospital's medication and safety procedures. Root Cause Analysis (RCA): To further understanding about latent systems gaps and process failure modes, an independent RCA of the event was conducted in June 2007. An external consultant team conducted a one-week evaluation of the medication use system and the organization's current environment, systems and processes, staffing patterns, leadership, and culture to help shape the recommended improvements. For each of the four proximate causes of the event, performance-shaping factors were identified. Although the hospital's organizational learning was painful, this event offered an opportunity for increasing organizational competency and capacity for designing and implementing patient safety. Structures and processes, including safety nets and fail-safe mechanisms, were implemented to promote safer behavioral choices for providers. Actions Taken: The hospital took a number of clinical steps to improve the safety of medication administration, including removing the barriers to scanning medication bar codes, implementing consistent scanning-compliance tracking, and providing teamwork training for all nursing and physician staff practicing in the birth suites.
机译：背景：2006年7月，一名16岁的患者来医院分娩。在她的护理过程中，将专门用于硬膜外途径的输注连接到患者的外周静脉管线，并通过泵进行输注。患者经历了心血管衰竭。剖宫产导致一个健康的婴儿分娩，但医疗团队无法使母亲复苏。当护士被指控犯有刑事罪行时，通过国家医疗服务提供者和安全界加快了媒体对错误的关注。这些事件引发了对医院药物和安全程序的内部和外部严格审查。根本原因分析（RCA）：为了进一步了解潜在系统的差距和过程失败模式，2007年6月对事件进行了独立的RCA。外部顾问团队对药物使用系统和组织的当前状况进行了为期一周的评估环境，系统和流程，人员配备模式，领导能力和文化，以帮助形成建议的改进。对于事件的四个最接近原因中的每一个，都确定了绩效塑造因素。尽管医院的组织学习很痛苦，但这次活动为提高组织能力和设计和实施患者安全能力提供了机会。实施了包括安全网和故障安全机制在内的结构和过程，以促进提供者更安全的行为选择。采取的行动：医院采取了许多临床步骤来提高药物管理的安全性，包括消除扫描药物条形码的障碍，实施一致的扫描合规性跟踪以及为所有在分娩时执业的护理人员和医师提供团队合作培训套房。

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