Neonatal ICU System Safety: A Pilot Test for Medication Error by Using Fuzzy Grey Relational Analysis.
This study analyzed risk factors for medication/near-miss errors in the neonatal intensive care unit by using Grey Relational Analysis based on self-incident reports from staff nurses. The ASSESS-ERR Medication System Worksheet was used. A total of 156 medication/near-miss errors were found across 5 stages of the medication use process. The order prescribing stage had the most errors. The highest systemic risk factors were critical drug information missing; environmental, staffing, and workflow problems; and lack of staff education.
School of Nursing, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China (Drs Zhang and Liu, and Ms Chen); School of Nursing, University of Texas at Tyler (Dr Lee); and WHO Collaborating Centre for Nursing Policy-Making and Quality Management, Beijing, China (Dr Liu).
Xin
X
Zhang
Shih-Yu
SY
Lee
Jingli
J
Chen
Huaping
H
Liu
D000328:Adult; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D007363:Intensive Care Units, Neonatal / Q000592:standards*; D050316:Medical Order Entry Systems; D008508:Medication Errors / Q000517:prevention & control / Q000706:statistics & numerical data*; D015233:Models, Statistical; D000067491:Near Miss, Healthcare; D017283:Neonatal Nursing / Q000193:education; D061214:Patient Safety; D010865:Pilot Projects; D012308:Risk Management / Q000379:methods*