환자안전사고 보고서를 통한 간호사 투약오류 분석
Analysis of Medication Errors of Nurses by Patient Safety Accident Reports
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목적: 본 연구의 목적은 최근 3년간의 간호사 투약오류의 특성을 파악하고 분석하기 위함이다. 방법: 환자안전 사고 중 간호사에 의한 투약오류를 분석하는 후향적 조사연구이다. 연구자료는 2017년 1월부터 2019년 12월까지 3년간 수집되었다. 자료는 SPSS 26.0 프로그램을 이용하여 빈도, 백분율, x2-test와 로지스틱 회귀분석을 이용하여 분석하였다. 연구결과: 전체 677건의 투약오류 중 간호사에 의한 오류는 275건(40.6%)이었다. 간호사 투약오류 중 근접오류 154건(56.0%), 정맥주사제 170건(61.8%), 잘못된 용량 102건(37.1%), 반복적인 업무에 대한 부주의가 98건(35.6%)으로 가장 많았다. 투약오류는 부서별, 간호사 경력별, 환자안전사고 유형별로 차이를 보였다. 로지스틱 회귀분석 결과 위해사건의 위험요인은 수액 주입(OR=3.93, 95% CI: 1.26∼12.27), 인슐린 피하주사(OR=39.06, 95% CI: 4.58∼333.18), 일혈/침윤(OR=7.26, 95% CI: 1.85∼28.53)의 발생으로 나타났다. 결론: 투약오류를 예방하는 가장 간단하고 효과적인 방법은 5 right를 지키는 것이며, 일반적인 교육보다는 부서별, 간호사 경력별로 차별화된 교육프로그램 개발이 필요하다. 투약바코드 시스템이나 팀간호 방법과 같은 병원 차원의 통합적 중재 또한 필요하다.
Abstract
Purpose: The purpose of this study was to identify and analyze the characteristics of nurses’ medication errors during three years. Methods: Retrospective survey study design was used to analyze medication errors by nurses among patient safety accidents. Data were collected for three years from January, 2017 to December, 2019. Data were analyzed using frequency, percentage, x2-test, and logistic regression with SPSS 26.0 program. Results: Of a total 677 medication errors, 40.6% were caused by nurses. Among the medication errors, near miss (n=154, 56.0%), intravenous bolus injection (n=170, 61.8%), wrong dose (n=102, 37.1%) and carelessness for repetitive work (n=98, 35.6%) were the most common. Medication errors differed by department, and nurses’ career, and patient safety accident type. The results of the logistic regression analysis showed that the risk factors of adverse events were medication of fluids (OR=3.93, 95% CI: 1.26~12.27), insulin subcutaneous injection (OR=39.06, 95% CI: 4.58~333.18), and occurrence of extravasation/infiltration (OR=7.26, 95% CI: 1.85~28.53). Conclusion: The simplest and most effective way to prevent medication errors is to keep 5 right, and a differentiated education program according to department and nurse career is needed rather than general education programs. Hospital-level integrated interventions such as a medication barcode system or a team nursing method are also necessary.
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