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 70 5 5 2005628200512 5 1Graduate 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, 200631
Ⅰ. はじめに 13 10 HP2001 1 20022001 Ⅱ. 用語の定義 Ⅲ. 研究方法 1. 研究対象 ( 資料 ) HP2001 472002 41 2003 331 3,724 2. 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 1999 2004 17 2002 200420022002 2002 2002 2001 200220032003 200220002000 2001 20032002 20022001 2000McCloskey et al.2002 2000 10 図 1 図 2 10 32 Vol 9, No 2, 2006
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 3,724 48313.0483 256 26 230 3. 分析方法 1 2 SHEL HP1999 Soft-ware Hard-wareEnvironmentLiveware Live -ware 5 3 5 SPSS11.0J for Windows p0.05 4. 倫理的配慮 Ⅳ. 結果 1. 確認エラーの分類 230 249 図 3 249 29.024.2 18.1 1) 確認段階 1 45 249 18.1 MS210 18 2 2 2 1 2) 確認段階 2 15 6.0 Vol 9, No 2, 200633
2 3 1 NS NS Yes 1 No 2 3 34 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
80 60 70 72 24.2 45 60 29.0 18.1 50 40 23 20 15 30 9.3 8.1 6.0 20 3 10 1.2 0 図 3 確認エラーの発生数 10 4.0 SHEL5 14214.0 555.4 12011.8 55855.0 14013.8 0 100 200 300 400 500 600 図 4 関連要因 (5 領域別 ) の数 3) 確認段階 3 7229.0 MS160 mg3 1 10 mg2 10 mg 1 4) 確認段階 239.3 5 確認段階 5 60 24.2 MS 2 2 6 確認段階 7 3 1.2 A B 7 確認段階 8 20 8.1 3 8 確認段階 10 10 4.0 2. 関連要因の分類 249 1,015 SHEL 5 142 14.0 55 5.4 120 11.8 558 55.0 140 13.8 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, 200635
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
0 20 40 60 80 100 2915.7 158.1 10255.1 3619.5 31.6 710.0 3752.9 1927.1 34.3 45.7 5116.4 17155.0 3410.9 268.4 299.3 1619.8 911.1 4454.3 911.1 33.7 5823.6 13956.5 187.3176.9 145.7 421.1 631.6 947.4 1319.7 34.5 410.838.1 23.0 2259.5 10.325df4p0.035 5 c 2 11.072df4p0.026 c 2 37.830df4p0.000 1 5 5 図 5 3756.1 1 102185 55.1 31.4 1 215.1 36 19.5 10.3 2 3770 52.9 1 3 24.3 19 27.1 21.4 3 139246 56.5 24.4 20.3 58 23.6 10.2 7.7 Ⅴ. 考察 1116.7 821.6 14214.0 12011.8 55855.0 14013.8 555.4 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, 200637
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 29.0 24.2 18.12001 0 2000 p.114 2. 確認エラーの関連要因について 82 Kohn & Corrigan 2000p.79 1 Kohn & Corrigan2000p.79 HP2004 2000 55.0 2000p.109 3. 確認エラーの予防対策 2000p.112114 5 38 Vol 9, No 2, 2006
5 1) 行動計画と指示の照合 確認段階 3 2002 2) 実行しようとしている行動と指示の照合 確認段階 5 2004 2003 2000 3) 指示 ( 行動目標 ) の把握 確認段階 1 2000p.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 1 18.1 29.0 24.2 3 70 2 5 Vol 9, No 2, 200639
5 5 謝辞 2001 26243249 2002 158392 2004 411 4753 2000 Evidence-Based Nursing52 22226 2000 31 63 65 2002 33 287289 2002 331214 2002 33 35 2001 12 9 30 2002 333 119121 2002 33278 280 2001 329496 2003 34 80 82 Kohn L.T. & Corrigan, J.M. 2000TO ERR IS HUMAN 79 2001 http://www.mhlw.go.jp/topics/2001/0110/tp1030-1. html McCloskey, J.C. & Bulechek, G.M. 2002NIC3664668 2003 348587 2000 42 2003 2815967 1999 http://www.nurse.or.jp/senmon/riskmanagement/ 005_1.html 2002 14 14 2000 12 521 2004 http://www.soumu.go.jp/s-news/2004/040312_1a1. html 2002 SHEL 33263265 199513 2002 33911 2002 33 4244 2000 40 Vol 9, No 2, 2006