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1 The Journal of the Japan Academy of Nursing Administration and Policies Vol 9, No 2, pp 3140, 2006 原著看護師の内服与薬業務における確認エラーに関する検討 Study of Confirmation Errors for Internal Use by Nurses 濱田康代 1) 田口大介 2) 酒井美絵子 3) 村田加奈子 3) 川村佐和子 4) Yasuyo HamadaDaisuke TaguchiMieko SakaiKanako MurataSawako Kawamura Key wordsmedication errors, confirmation 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 confirmation. So far, there are few reports which analyzed the factors related to the causes or the stages of malpractice occurrence. In this study, confirmation errors identified from the incidents reported in the government publication were categorized according to our own algorithm and analyzed to determine the contributing factors. The findings were : Confirmation errors, which comprised 70% of all errors, occurred at the stages of confirming 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 provision with the doctor s order. The confirmation errors involved with the nurse s acceptance of orders, or with the nurse s actions as indicated above, in addition to confirmation involved with the nurse s evaluation of the validity of orders were categorized by five items of causal factors. A significant difference was observed between the distribution of the related causal factors and that of the entire items of confirmation. Preventive measures should be programmed at each confirmation process. 要 Graduate School of Human Sciences, Waseda University 2Nursing Department, Keio University Hospital 3Faculty of Health Sciences, Tokyo Metropolitan University 4Graduate School of Health Sciences, Aomori University of Health and Welfare 旨 Vol 9, No 2,

2 Ⅰ. はじめに HP Ⅱ. 用語の定義 Ⅲ. 研究方法 1. 研究対象 ( 資料 ) HP , データ収集方法 1) 内服与薬業務における看護師の確認プロセスに関するアルゴリズムの作成 web McCloskey et al 図 1 図 Vol 9, No 2, 2006

3 図 1 行動モニターモデルとアルゴリズムの関係 2) 事例の抽出 3, 分析方法 1 2 SHEL HP1999 Soft-ware Hard-wareEnvironmentLiveware Live -ware SPSS11.0J for Windows p 倫理的配慮 Ⅳ. 結果 1. 確認エラーの分類図 ) 確認段階 MS ) 確認段階 Vol 9, No 2,

4 2 3 1 NS NS Yes 1 No Vol 9, No 2, 2006 図 2 内服与薬業務における看護師の確認プロセス : アルゴリズム

5 図 3 確認エラーの発生数 SHEL 図 4 関連要因 (5 領域別 ) の数 3) 確認段階 MS160 mg mg2 10 mg 1 4) 確認段階確認段階 MS 確認段階 A B 7 確認段階確認段階関連要因の分類 249 1,015 SHEL 図 4 3. 確認エラーと関連要因の関係 5 5 表 1 5 5c 2 Vol 9, No 2,

6 表 1 確認段階別の関連要因の構成 1 マニュアル規定 Soft-ware 医療機器物 Hard-ware 環境 Environment 当事者 Live-ware 関係者 Live -ware 36 Vol 9, No 2, 2006

7 df4p c df4p0.026 c df4p 図 Ⅴ. 考察図 5 各確認段階における関連要因 (SHEL) の割合 1,015 Vol 9, No 2,

8 1. 内服与薬業務プロセスにおける確認エラーの発生段階について p 確認エラーの関連要因について 82 Kohn & Corrigan 2000p.79 1 Kohn & Corrigan2000p.79 HP p 確認エラーの予防対策 2000p Vol 9, No 2, 2006

9 5 1) 行動計画と指示の照合確認段階 ) 実行しようとしている行動と指示の照合確認段階 ) 指示 ( 行動目標 ) の把握確認段階 p.118 4) 指示と根拠の照合確認段階 2 Ⅵ. 本研究の限界と今後の課題 Ⅶ. 結論 Vol 9, No 2,

10 5 5 謝辞 Evidence-Based Nursing Kohn L.T. & Corrigan, J.M. 2000TO ERR IS HUMAN html McCloskey, J.C. & Bulechek, G.M. 2002NIC _1.html html 2002 SHEL Vol 9, No 2, 2006

The Journal of the Japan Academy of Nursing Administration and Policies Vol 12, No 1, pp 49 59, 2008 資料看護師におけるメンタリングとキャリア結果の関連 Relationship between M

The Journal of the Japan Academy of Nursing Administration and Policies Vol 12, No 1, pp 49 59, 2008 資料看護師におけるメンタリングとキャリア結果の関連 Relationship between Mentoring and Career Outcomes of Nurses 今堀陽子 1) 作田裕美