進階搜尋


下載電子全文  
系統識別號 U0026-2907201503575400
論文名稱(中文) 探討急診新人醫療錯誤並設計創新訓練介入計畫
論文名稱(英文) Studying ER Medical Error to the Design of Training Interventions for Novice Nurses
校院名稱 成功大學
系所名稱(中) 工業設計學系
系所名稱(英) Department of Industrial Design
學年度 103
學期 2
出版年 104
研究生(中文) 賴學儀
研究生(英文) Hsueh-Yi Lai
學號 P36024116
學位類別 碩士
語文別 英文
論文頁數 77頁
口試委員 指導教授-洪郁修
口試委員-陳建旭
口試委員-陳清惠
口試委員-施欣怡
口試委員-林明毅
中文關鍵字 系統性觀點  新人護理師  顯性失誤  隱性失誤  訓練失誤 
英文關鍵字 system approach  novice nurse  active error  latent error  training failure 
學科別分類
中文摘要 急診室相當容易產生醫療錯誤,而其中又屬於急診新人護理師為發生醫療錯誤的高危險族群,本研究的目的為探討現行急診醫療錯誤的發生情形並設計創新訓練介入計畫,首先透過系統性的觀點進行切入,以顯性人為失誤、隱性系統失誤探討常見的急診醫療錯誤的成因,並研究現行訓練現況的缺失,藉以針對錯誤成因進行創新的訓練介入計畫;而本研究進行半結構式訪談以了解現行急診錯誤發生的情形,總計34名急診護理人員,其中15名為訓練員、19名為新人護理師,並透過內容分析法對文本資料進行探討。在研究結果方面,將依據醫療錯誤特性並分為四個領域,分別為給藥方面失誤、檢體送檢錯誤、延誤遺忘處理病況惡化、儀器管路設定操作錯誤。其中給藥失誤發生頻率最多,在顯性失誤方面多屬於技術型遺漏失誤,而技術型作為失誤次之,錯誤情形為護理師未能確實在執行醫囑前進行三讀五對,進而導致護理師遺漏進行藥物劑量、途徑、品項的核對,或是不小心給予錯藥物劑量、途徑的情形,而錯誤的產生可歸因於隱性失誤,包含心理前兆、文化氛圍,心理前兆代表護理師經常受外在環境干擾而產生心理的認知負荷,而文化氛圍則為急診環境普遍存有搶快處理的氛圍,導致護理師並未確實執行核對便執行給藥。在檢體送檢錯誤方面,顯性失誤情形包含技術型遺漏失誤以及規則型遺漏失誤,前者代表護理師即常遺漏核對檢體身分或是黏貼檢體身分標籤,而後者代表新人護理師對於步驟不熟悉而未能正確抽取檢體;而相關隱性失誤方面,除了心理前兆造成的影響外,也與不良的團隊合作有關,護理師在幫忙同事執行口頭囑託時,經常遺忘再次確認其正確性,導致重複送檢體以及抽錯病患檢體的情形。在延誤遺忘處理病況惡化方面,其顯性錯誤多為規則型遺漏失誤,代表新人護理師未能及時察覺到病患病況的惡化徵兆,而遺漏第一時間進行處置,相關隱性錯誤除了心理前兆的影響外,訓練失誤也有很大的影響,代表現有訓練體系無法讓護理師將相關知識靈活運用到臨床環境中;而最後在儀器管路設定操作錯誤方面,則以規則型遺漏失誤為主、技術型遺漏失誤次之,前者之錯誤情形為護理師未及時對躁動病患採取約束或鎮靜,導致插管自拔的情形,而後者錯誤情形為新人護理師在交班時,經常遺忘再次確認病患管路情況,導致最後管路滑脫,或是在使用點滴幫浦時,遺忘在次核對給藥速率導致給藥過快;而相關隱性失誤除了心理前兆情形外,不良的團隊合作也是錯誤產生的主因,失誤產生情形為照護團隊未釐清照護管路的責任,導致插管病患轉送加護病房時產生插管自拔的情形。而在現行急診訓練狀況中,新人護理師認為現行課程多提供知識而缺乏實際知識操練,導致課程未能符合實際需求,此外,臨床課程的教學內容大多以當下情況為主,而缺乏系統化的教學內容。

而本研究的貢獻在於透過系統性的出發點看待急診錯誤的發生,除了能給未來急診錯誤相關研究啟發之外,也能據此提出具體有效的訓練介入建議,總體建議為: 在給藥錯誤方面,透過大量的核對練習提升熟練度及經診度外,訓練新進人員熟悉在時間壓力之下進行處置,此外也透過給予臨床提示小冊子、案例討論的方式,讓新人隨時複習藥物知識以及活用知識進行處置而非死記硬背;在檢體送檢錯誤方面,則提供相關送檢流程細節的提示手冊,隨時讓新人查閱繁雜的送檢流程知識,並透過在相關儀器,如試管、送檢處進行標示,隨時提醒新進人員處理細節;在延誤遺忘處理病況惡化方面,訓練單位應該整理出病患症狀如何判讀以及處置辦法,並訓練新進人員即使在壓力之下也能敏感的發現病況的變化,此外也必須訓練新人如何將為數眾多的任務依優先性進行安排,而非因忙於雜事反而遺漏真正該進行的處置。在儀器管路設定操作錯誤方面,則透過實際完整流程的操作,並給予指定任務,讓新進人員能學會如何確實操作儀器。
英文摘要 Emergency (ER) departments are a particularly error-prone treatment setting, in which ER novice nurses are a group at high risk of generating medical errors. This study investigated the occurrence of ER medical errors to design innovative training interventions for novice nurses. First, by using a system approach, we examined active and latent errors to investigate the causes of common ER medical errors, and then analyzed deficiencies in current training programs. The results were used to design innovative training interventions for mitigating medical errors that occur in ER settings. Semistructured interviews with 34 ER nurses (15 preceptors and 19 novice nurses) were conducted to determine extant medical errors occurring in ER departments. Subsequently, content analysis was performed on the collected interview texts and data. The research results were then analyzed according to the characteristics of medical errors and four categories of medical errors were identified: (1)medication error, (2)error in sample submission for testing, (3)delay in treating and forgetting to treat deteriorating patients, (4)error in equipment and tube setting. Among these types of errors, medication error occurred the most frequently. In terms of active errors, medication error most frequently occurred in the form of skill-based error of omission, followed by skill-based error of commission. It means novice nurse often forget to obey “five rights” before executing order. The occurrence of these errors attributes to latent error, including excessive psychological precursors, and rash working atmosphere. In terms of error in sample submission for testing involved skill-based error of omission, and rule-based error of omission. The former error means novice nurse often forget to paste sticker of specimen, leading to the failure of identifying specimen identity. The latter error refers to novice nurse fail to proceed right process to take specimen. And these error attributes to not only psychological precursors but also poor team work where novice nurse often carry out other nurses’ oral request without checking if the request is right or not. Concerning delaying in treating and forgetting to treat deteriorating patients, it’s associated with rule-based error of omission. It means novice nurse often miss the symptom of patients, giving rise to the omission of carrying out treatment in time. Apart from psychological precursors, training failure is also responsible for the occurrence of error. Inadequate training leads novice nurse unable to utilize knowledge in hand and do proper time management in clinical settings. Finally, error in equipment and tube setting was mostly associated with rule-based error of omission, followed by skill-based error of omission. The former error represents novice nurse often neglect the necessity of execute constraint or sedation on patients leading to patient extubated himself. The letter one means novice nurse forget to recheck the tube during the shift, leading to slippage off where it supposed to be. And these error attributes to excessive psychological precursors and poor team work where nursing staff fail to clarify responsibility of caring patients with intubation. In terms of the status of quo of training program. Novice nurses thought that existing course lack of the utilization of knowledge and actual operation. Further, most of training content depends on what clinical situation they encountered without systematic organization of teaching.

This study contributed to relevant research fields by providing an analysis of ER medical errors from a systematic perspective. The findings can serve not only as inspirations for future research on ER medical errors, but also as a reference for designing concrete and effective training interventions. This study provides the following recommendations. Medication errors can be minimized by assigning nurses multiple practical exercises to improve their proficiency and precision in administering drugs to patients. Novice nurses should be familiar with nursing procedures so that they could efficiently carry out the procedures even under time constraints. Furthermore, novice nurses could be provided with clinical handbooks that allow them to revise drug-related knowledge at any time. They should participate in case study discussions where they can really apply their knowledge rather than engage in rote learning. To address error in sample submission for testing, handbooks detailing relevant processes could be provided to novice nurses so that they could search for and learn complex procedures at any time. In addition, relevant instruments, test tubes, and specimen samples should be clearly labeled to serve as a reminder to novice nurses about paying attention to detail. To mitigate error in equipment and tube setting, novice nurses could learn how to operate instruments by showing them the actual operations of an entire process and assigning them practice tasks. Regarding delay in treating and forgetting to treat deteriorating patients, training units should compile a guideline to determining and treating patient symptoms and train novices to develop heightened sensitivity toward changes in disease conditions, even when in a stressful environment. Finally, novices must also be trained in sorting the priority of multiple tasks to prevent focusing on miscellaneous issues and consequently omit executing procedures that are really needed.
論文目次 口試通過證明 i
摘要 ii
Abstract iv
Acknowledgement vii
TABLE OF CONTENTS viii
LIST OF TABLES xi
LIST OF FIGURES xii
Chapter 1 Introduction 1
1.1 Research Background and Motivation 1
1.2 Research Objectives 4
1.3 Research Scope 5
Chapter 2 Literature Review 6
2.1 Systematic Risk Analysis and Management 6
2.2 Active Errors 6
2.2.1 Active Errors: Human Errors 7
2.2.2 Active Errors: Types of Errors 9
2.3 Latent Errors 9
2.3.1 Latent Errors: Design Failure 10
2.3.2 Latent Errors: Organization and Environment Failure 10
2.4 Summary 11
Chapter 3 Research Method 13
3.1 Participants 13
3.2 Instrument 15
3.3 Semistructured Interview 15
3.4 Data Analysis 17
Chapter 4 Results 21
4.1 Medication Error 21
4.1.1 Condition of Error 21
4.1.2 Causation of Active Error 22
4.1.2 Causation of Latent Error 24
4.1.3 Systematic Overview of Error Causation 27
4.2 Error in Sample Submission for Testing 29
4.2.1 Condition of Error 29
4.2.2 Causation of Active Error 29
4.2.3 Causation of Latent Error 31
4.2.4 Systematic Overview of Error Causation 33
4.3 Delay in Treating and Forgetting to Treat Deteriorating Patients 34
4.3.1 Condition of Error 34
4.3.2 Causation of Active Error 34
4.3.3 Causation of Latent Error 35
4.3.4 Systematic Overview of Error Causation 37
4.4 Error in Equipment and Tube Setting 38
4.4.1 Condition of Error 38
4.4.2 Causation of Active Error 38
4.4.3 Causation of Latent Error 40
4.4.4 Systematic Overview of Error Causation 41
4.5 Current Situation of Emergency Medicine Training 42
4.5.1 Problems in Formal Training Programs 43
4.5.2 Problems in Informal Training Programs 44
4.5.3 Training Suggestions as Proposed by Interviewees 47
4.5.4 Summary 49
Chapter 5 Discussion 51
5.1 Causation of Medication Error 51
5.2 Causation of Error in Sample Submission for Testing 54
5.3 Causation of Delaying Treatment/Forgetting to Treat Deteriorating Patient 55
5.4 Causation of Error in Equipment and Tube Setting 57
5.5 Error in Current Emergency Medicine Training Models 59
5.5.1 Formal Training 59
5.5.2 Informal Training 60
Chapter 6 Design Recommendations 64
6.1 Preventing Medication Error 64
6.2 Preventing Error in Sample Submission for Testing 66
6.3 Preventing Delay in and Forgetting Treatments 67
6.4 Prevention of Error in Equipment and Tube Setting 69
Chapter 7 Conclusion 71
Reference 75

參考文獻 Adhikari, N. (2011). Medical Harm and Patient Safety-II: Medication Errors. Journal of Nepal Paediatric Society, 31(1), 75-79.
Bagnasco, A., Tubino, B., Piccotti, E., Rosa, F., Aleo, G., Di Pietro, P., . . . Gambino, L. (2013). Identifying and correcting communication failures among health professionals working in the Emergency Department. International emergency nursing, 21(3), 168-172.
Basole, R. C., Braunstein, M. L., Kumar, V., Park, H., Kahng, M., Chau, D. H. P., . . . Bost, J. (2015). Understanding variations in pediatric asthma care processes in the emergency department using visual analytics. Journal of the American Medical Informatics Association, ocu016.
Benner, P., Sheets, V., Uris, P., Malloch, K., Schwed, K., & Jamison, D. (2002). Individual, practice, and system causes of errors in nursing: a taxonomy. Journal of Nursing Administration, 32(10), 509-523.
Berkow, S., Virkstis, K., Stewart, J., & Conway, L. (2009). Assessing new graduate nurse performance. Nurse educator, 34(1), 17-22.
Bisholt, B. K. (2012). The learning process of recently graduated nurses in professional situations—experiences of an introduction program. Nurse Education Today, 32(3), 289-293.
Bleetman, A., Sanusi, S., Dale, T., & Brace, S. (2012). Human factors and error prevention in emergency medicine. Emergency Medicine Journal, 29(5), 389-393.
Blume, B. D., Ford, J. K., Baldwin, T. T., & Huang, J. L. (2010). Transfer of training: A meta-analytic review. Journal of Management, 36(4), 1065-1105.
Brown, M. (2005). Medication safety issues in the emergency department. Critical care nursing clinics of North America, 17(1), 65-69.
Burke, L. A., & Hutchins, H. M. (2007). Training transfer: An integrative literature review. Human resource development review, 6(3), 263-296.
Cosby, K. S. (2003). A framework for classifying factors that contribute to error in the emergency department. Annals of emergency medicine, 42(6), 815-823.
Croskerry, P., & Sinclair, D. (2001). Emergency medicine: a practice prone to error. Cjem, 3(4), 271-276.
Ebright, P. R., Urden, L., Patterson, E., & Chalko, B. (2004). Themes surrounding novice nurse near-miss and adverse-event situations. Journal of Nursing Administration, 34(11), 531-538.
Grossman, R., & Salas, E. (2011). The transfer of training: what really matters. International Journal of Training and Development, 15(2), 103-120.
Harding, L., & Petrick, T. (2008). Nursing student medication errors: a retrospective review. The Journal of nursing education, 47(1), 43-47.
Hickey, M. T. (2009). Preceptor perceptions of new graduate nurse readiness for practice. Journal for Nurses in Professional Development, 25(1), 35-41.
Hutchins, H. M., & Burke, L. A. (2007). Identifying preceptors' knowledge of training transfer research findings–closing the gap between research and practice. International Journal of Training and Development, 11(4), 236-264.
Itoh, K., Andersen, H. B., & Madsen, M. D. (2006). Safety Culture in Healthcare, In P. Carayon (ed.), Handbook of Human Factors and Ergonomics in Healthcare and Patient Safety. Safety Culture in Healthcare, In P. Carayon (ed.), Handbook of Human Factors and Ergonomics in Healthcare and Patient Safety, 199-216.
Kenward, K., & Zhong, E. (2006). Report of findings from the practice and professional issues survey, fall 2004. National Council of State Boards of Nursing (NCSBN) Research Brief, 22, 1-2.
Kohn, L., Corrigan, J., & Donaldson, M. (2010). Institute of Medicine (2000). To err is human: Building a safer health system: Washington, DC: The National Academies Press.
Lammers, R., Byrwa, M., & Fales, W. (2012). Root causes of errors in a simulated prehospital pediatric emergency. Academic Emergency Medicine, 19(1), 37-47.
Leape, L. L. (1994). Error in medicine. Jama, 272(23), 1851-1857.
Leape, L. L. (1997). A systems analysis approach to medical error. Journal of evaluation in clinical practice, 3(3), 213-222.
Marler, J. H., Liang, X., & Dulebohn, J. H. (2006). Training and effective employee information technology use. Journal of Management, 32(5), 721-743.
Mazzocco, K., Petitti, D. B., Fong, K. T., Bonacum, D., Brookey, J., Graham, S., . . . Thomas, E. J. (2009). Surgical team behaviors and patient outcomes. The American Journal of Surgery, 197(5), 678-685.
Meyer, E., Lees, A., Humphris, D., & Connell, N. (2007). Opportunities and barriers to successful learning transfer: impact of critical care skills training. Journal of Advanced Nursing, 60(3), 308-316.
Morrow, S. (2009). New graduate transitions: leaving the nest, joining the flight. Journal of nursing management, 17(3), 278-287.
Norman, G. (2009). Dual processing and diagnostic errors. Advances in health sciences education, 14(1), 37-49.
Pham, J. C., Aswani, M. S., Rosen, M., Lee, H., Huddle, M., Weeks, K., & Pronovost, P. J. (2012). Reducing medical errors and adverse events. Annual review of medicine, 63, 447-463.
Pham, J. C., Story, J. L., Hicks, R. W., Shore, A. D., Morlock, L. L., Cheung, D. S., . . . Pronovost, P. J. (2011). National study on the frequency, types, causes, and consequences of voluntarily reported emergency department medication errors. The Journal of emergency medicine, 40(5), 485-492.
Purling, A., & King, L. (2012). A literature review: graduate nurses' preparedness for recognising and responding to the deteriorating patient. Journal of clinical nursing, 21(23-24), 3451-3465.
Rasmussen, J. (1983). Skills, rules, and knowledge; signals, signs, and symbols, and other distinctions in human performance models. Systems, Man and Cybernetics, IEEE Transactions on(3), 257-266.
Reader, T., Flin, R., Lauche, K., & Cuthbertson, B. H. (2006). Non-technical skills in the intensive care unit. British Journal of Anaesthesia, 96(5), 551-559.
Reason, J. (1990). Human error: Cambridge university press.
Saintsing, D., Gibson, L. M., & Pennington, A. W. (2011). The novice nurse and clinical decision‐making: how to avoid errors. Journal of nursing management, 19(3), 354-359.
Shorr, R. I., Mion, L. C., Chandler, A. M., Rosenblatt, L. C., Lynch, D., & Kessler, L. A. (2008). Improving the capture of fall events in hospitals: combining a service for evaluating inpatient falls with an incident report system. Journal of the American Geriatrics Society, 56(4), 701-704.
Simmons, R. L. (2003). Reducing medical errors: An organizational approach. P AND T, 28(12), 780-790.
Smith, J., & Crawford, L. (2003). Medication errors and difficulty in first patient assignments of newly licensed nurses. JONA'S healthcare law, ethics and regulation, 5(3), 65-67.
Smits, M., Zegers, M., Groenewegen, P., Timmermans, D., Zwaan, L., Van der Wal, G., & Wagner, C. (2010). Exploring the causes of adverse events in hospitals and potential prevention strategies. Quality and Safety in Health Care, 19(5), 1-7.
Swain, A. D., & Guttmann, H. E. (1983). Handbook of human-reliability analysis with emphasis on nuclear power plant applications. Final report: Sandia National Labs., Albuquerque, NM (USA).
Swensen, S. J., Meyer, G. S., Nelson, E. C., Hunt Jr, G. C., Pryor, D. B., Weissberg, J. I., . . . Chassin, M. R. (2010). Cottage industry to postindustrial care—the revolution in health care delivery. New England Journal of Medicine, 362(5).
Tanaka, M., Tanaka, K., Takano, T., Kato, N., Watanabe, M., & Miyaoka, H. (2012). Analysis of risk of medical errors using structural-equation modelling: a 6-month prospective cohort study. BMJ quality & safety, 21(9), 784-790.
Wears, R. L., Woloshynowych, M., Brown, R., & Vincent, C. A. (2010). Reflective analysis of safety research in the hospital accident & emergency departments. Applied ergonomics, 41(5), 695-700.
論文全文使用權限
  • 同意授權校內瀏覽/列印電子全文服務,於2015-08-11起公開。
  • 同意授權校外瀏覽/列印電子全文服務,於2015-08-11起公開。


  • 如您有疑問,請聯絡圖書館
    聯絡電話:(06)2757575#65773
    聯絡E-mail:etds@email.ncku.edu.tw