Abstract
Patient safety has become a global issue. In Taiwan, the aim of Taiwan Patient safety Reporting system building is to collect and rethink happened medical adverse event from which we could learn to decrease rate of medical error. In such many kinds of adverse event, medication safety is one of main concern. Unappreciated used of drug treatment not only will threat patient lives but crush medical system and social structure and heavy the financial loading of hospital and government. It’s important to enhance drug safety through medication adverse event (MAE) collected from reporting system. The main purposes of this research are to investigate nurses’ cognition of MAE and the way they report MAE, also find out the reasons and factors behind their report and the way they look at event. Researcher constructed open-end scenario report, subjective ranking scale and semi-structure individual interview. The open-end scenario report is based on real medication adverse events. Through the analysis of nurses reporting models of MAE and the missed items in their reports, researcher calculated the integrity and effectiveness score. The semi-structure individual interview will used to investigate the reasons behind reporting models, reporting criterion and other MAE concepts of nurses. At last, the subjective ranking scale is designed for importance ranking of reporting needed items in reporting system. Researcher recruited 30 nurses to be participants in formal experiment. All participants were divided into 3 groups based on their working years: 9 participants for senior group, 11 participants for middle working experience group, 10 participants for junior group. In the result part, nurses reporting models could be divided into four types: “integrated report” (report with full case description, wrong doing and correction and improvement), “partial report” (report with part case description, wrong doing and correction and improvement), “review report” (report with wrong doing and correction and improvement), and “event report” (report with full case description). The middle working experience group use “integrated report” the most, and then is junior group. The senior group is prone to use “review report”. The reasons may have relevance with “reporting system design”, “training” and “report time interval”. The integrity and effectiveness score among three groups aren’t statistical significantly different, but the middle working experience group performed higher score trend than others. The reporting models, the complexity of scenarios and the experiment time may lead to this kind of results. The reasons of missing items are “dependence of click system”, “poor reporting habit” and “reporting experience” and “fatigue mental condition”. In the cause analysis part, all participants could focus on personal factors, but less than half of participants could focus on multi-personal factors, and only 28% could focus on systematic factors. Researcher infers that nurses’ concept of cause analysis which is generally not systematic oriented will causes the percentage distribution. In the subjective ranking scale part, participants think that information related to MAE, correction and patient first aid are the most important. Based on the results, Medical adverse event reporting should focus on reporting system design and reporting culture. Reporting system design should apply ergonomics design, reporter should understand the meaning of reported items while they’re using the system. Reporting system should also avoid making user depend too much and weakening own ability of organizing report and emphasize the items reporter thinks are important. Report culture should focus on the change of patient safety culture inside medical institution. The change patient safety culture will affect staffs attitude and behavior. Training should focus on the construction of nurses’ concepts, and make them realize the importance, meaning and purpose of each reported item. Elevate front-line nurse reporting quality will do a lot on medical safety improvement.