护士经历接近失误事件质性研究的Meta整合

doi:10.3761/j.issn.2096-7446.2024.09.006

Abstract

Abstract: Objective To systematically evaluate near misses experienced by nurses to inform better management of the situation. Methods A computerized search of PubMed,Cochrane Library,Web of Science,Embase,PsycInfo,Scopus,China National Knowledge Infrastructure,Wanfang,VIP,and China Biomedical Literature Database for qualitative studies on nurses‘ experience of near miss events was conducted with a timeframe of the establishment of the database to December 30,2023. The quality of the included literature was evaluated using the 2016 Australian Joanna Briggs Institute（JBI） Center for Evidence-Based Health Care qualitative research quality assessment tool,and the results were integrated using meta-integration methods. Results A total of 7 articles were included,and 26 findings were distilled and grouped into 6 categories,resulting in 3 integrative findings,including reasons why near miss events occur,a dual emotional experience caused by near miss events,and ways of coping with near miss events. Conclusion Nursing administrators should pay more attention to the negative emotional experience that near miss events bring to nurses,improve the process of reporting near miss events,and establish a no-blame,nonpunitive management system,so as to promote nurses to report near miss events proactively and protect patient safety.

Key words: Nurses, Near Miss, Experience, Qualitative Research, Meta Integration, Evidence-Based Nursing

YU Ran, MA Xinxuan, GAN Qingwen, LIAN Zerong, SUN Xiaoxuan, LING Hua. Nurses‘ experiences of near-miss events：a qualitative meta-synthesis[J]. Chinese Journal of Emergency and Critical Care Nursing, 2024, 5(9): 806-811.

References

[1] Makary MA,Daniel M.Medical error-the third leading cause of death in the US[J]. BMJ,2016,353:i2139.
[2] 中国医院协会. 中国医院协会患者安全目标(2017版)[EB/OL].(2016-12-26)[2023-12-29]. https://www.cha.org.cn/site/content/9773fc6a8ebec5fdb57dc97ddf282e14.html.
Chinese Hospital Association. China hospital association patient safety goals(2017 edition)[EB/OL]. (2016-12-26)[2023-12-29]. https://www.cha.org.cn/site/content/9773fc6a8ebec5fdb57dc97ddf282e14.html.
[3] 朱建妹,梁志金,万玫,等. 护理接近失误原因分析及预防研究进展[J]. 护理学杂志,2021,36(15):102-105.
Zhu JM,Liang ZJ,Wan M,et al.Causal analysis and prevention of near miss incidents in nursing:a review[J]. J Nurs Sci,2021,36(15):102-105.
[4] 冯婷婷,张欣,谭玲玲,等. 护理接近失误管理的研究进展[J]. 中华护理杂志,2020,55(1):153-157.
Feng TT,Zhang X,Tan LL,et al.A literature review of nursing management for near miss[J]. Chin J Nurs,2020,55(1):153-157.
[5] Joanna Briggs Institute. JBI critical appraisal checklist for qualitative research[EB/OL]. (2016-08-03)[2023-06-03]. http://joanna briggs.org/assets/docs/critical0appraisal0tools.html.
[6] 胡雁. 如何开展质性研究的系统评价和Meta整合[J]. 上海护理,2020,20(7):1-5.
Hu Y.How to carry out systematic review and meta-synthesis of qualitative studies[J]. Shanghai Nurs,2020,20(7):1-5.
[7] 李传圣,张振宇,高明晓,等. ICU护理人员经历接近失误事件心理体验的质性研究[J]. 护士进修杂志,2023,38(12):1084-1087.
Li CS,Zhang ZY,Gao MX,et al.Qualitative study on the psychological experience of nursing staff experiencing near-miss events in ICU[J]. J Nurses Train,2023,38(12):1084-1087.
[8] 喻娇,刘佳,乔贵雪. 儿科病房护士工作中经历接近失误事件后的质性研究[J]. 中国乡村医药,2022,29(24):73-75.
Yu J,Liu J,Qiao GX.Qualitative study on nurses in pediatric wards after experiencing near-error events in their work[J]. Chin J Rural Med Pharm,2022,29(24):73-75.
[9] 田云伟,李善玲,田文雯,等. 护理人员接近失误事件认知的质性研究[J]. 护理学报,2022,29(7):32-35.
Tian YW,Li SL,Tian WW,et al.Qualitative research of cognition on near-miss events in nursing staff[J]. J Nurs China,2022,29(7):32-35.
[10] Park JH,Kong KR.A phenomenological study on nurses‘ experience of near miss in medication administration[J]. J Korean Acad Nurs Adm,2021,27(3):127.
[11] Lee J.Understanding nurses‘ experiences with near-miss error reporting omissions in large hospitals[J]. Nurs Open,2021,8(5):2696-2704.
[12] Colldén Benneck J,Bremer A.Registered nurses‘ experiences of near misses in ambulance care:A critical incident technique study[J]. Int Emerg Nurs,2019,47:100776.
[13] Kingston MJ,Evans SM,Smith BJ,et al.Attitudes of doctors and nurses towards incident reporting:a qualitative analysis[J]. Med J Aust,2004,181(1):36-39.
[14] 高慧敏,田凌云,粟亚男,等. 针刺伤相关风险管理及防护理论的应用进展[J]. 中华护理杂志,2020,55(6):937-942.
Gao HM,Tian LY,Su YN,et al.Application progress in risk management and protection theory of needlestick injuries[J]. Chin J Nurs,2020,55(6):937-942.
[15] 周雪阳,梁建凤,王小合,等. 杭州市医务人员病人安全文化认知水平及对不良事件报告频率的影响[J]. 医学与社会,2019,32(2):88-92.
Zhou XY,Liang JF,Wang XH,et al.Medical staffs‘ cognition level on patient safety culture and its influence on frequency of adverse events reported in Hangzhou city[J]. Med Soc,2019,32(2):88-92.
[16] Idilbi N,Dokhi M,Malka-Zeevi H,et al.The relationship between patient safety culture and the intentions of the nursing staff to report a near-miss event during the COVID-19 crisis[J]. J Nurs Care Qual,2023,38(3):264-271.
[17] Bryan R,Aronson JK,Williams A,et al.The problem of look-alike,sound-alike Name errors:drivers and solutions[J]. Br J Clin Pharmacol,2021,87(2):386-394.
[18] 吕永利,耿力,丁颖. 经历不良事件后离职的低年资护士的感受及应对措施的质性研究[J]. 中华护理杂志,2020,55(9):1320-1324.
Lü YL,Geng L,Ding Y.A qualitative study on feelings and coping measures of junior nurses leaving after adverse events[J]. Chin J Nurs,2020,55(9):1320-1324.
[19] 周淑芬,刘翠青,谢翠媚,等. 护理不良事件与安全隐患上报双轨化管理的实施效果[J]. 护理学报,2018,25(5):24-26.
Zhou SF,Liu CQ,Xie CM,et al.Implementation effect of dual-track management for reporting nursing adverse events and potential safety hazards[J]. J Nurs China,2018,25(5):24-26.
[20] 于冉,甘青文,连泽荣,等. ICU护士道德困境体验质性研究的Meta整合[J]. 中华急危重症护理杂志,2023,4(11):1000-1005.
Yu R,Gan QW,Lian ZR,et al.Meta-integration of a qualitative study on the experience of ethical dilemmas of ICU nurses[J]. Chin J Emerg Crit Care Nurs,2023,4(11):1000-1005.
[21] Haw C,Stubbs J,Dickens GL.Barriers to the reporting of medication administration errors and near misses:an interview study of nurses at a psychiatric hospital[J]. J Psychiatr Ment Health Nurs,2014,21(9):797-805.
[22] Noor NHM,Joibe KF,Hasan MN.Prevalence of near-miss events of transfusion practice and its associated factors amongst house officers in a teaching hospital[J]. Oman Med J,2021,36(2):e249.
[23] 刘静,冯婷婷,殷花丽,等. 基于跨层次组织学习动态模型的接近失误组织学习方案的实施及效果评价[J]. 中国护理管理,2022,22(7):1065-1069.
Liu J,Feng TT,Yin HL,et al.Implementation and effect evaluation of the near miss management scheme based on the 4I Framework of Organizational Learning[J]. Chin Nurs Manag,2022,22(7):1065-1069.

Nurses‘ experiences of near-miss events：a qualitative meta-synthesis

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