参考文献/References:
［1］Natan MB,Sharon I，Mahajna M,et al. Factors affecting nursing students' intention to report medication errors: an application of the theory of planned behavior［J］.Nurse Educ Today,2017, 58: 38-42.
［2］Donaldson LJ,Kelley ET, Dhingra-Kumar N,et al.Medication without Harm: WHO's third global patient safety challenge［J］.The Lance,2017, 389 (10080): 1680-1681.
［3］Koyama AK,Maddox CSS,Li L,et al.Effectiveness of double checking to reduce medication administration errors: a systematic review ［J］.BMJ Open Access,2020, 29 (7): 595-603.
［4］Eiland LS, Benner K, Gumpper KF, et al.ASHP-PPAG guidelines for providing pediatric pharmacy services in hospitals and health systems［J］.Narnia,2018, 75 (15):1151-1165.
［5］钟林涛,李朋梅,张镭,等. 患者安全目标:确保用药与用血安全［J］.中国卫生质量管理，2020,27（6） :13-16.
［6］Alomari A,Sheppard-Law S,Lewis J,et al. Effectiveness of clinical nurses' interventions in reducing medication errors in a paediatric ward［J］.Journal of Clinical Nursing, 2020, 29 (17-18): 3403-3413.
［7］Watters DAK, Truskett PG.Reducing errors in emergency surgery［J］.Anz Journal of Surgery，2013, 83 (6): 434-437.
［8］谭然,曹英娟,夏京花,等. 护士发生用药错误心理体验质性研究的系统评价［J］.中华护理杂志, 2020, 55 (5): 740-746.
［9］Aboumrad M,Fuld A,Soncrant C,et al. Root cause analysis of oncology adverse events in the veterans health administration［J］.Journal of Oncology Practice, 2018,14 (9):579-587.
［10］Balakrishnan K,Brenner MJ, Gosbee JW,et al. Patient safety/quality improvement primer, part II: prevention of harm through root cause analysis and action (RCA2) ［J］.Otolaryngology Head and Neck Surgery,2019, 161(6):911-921.
［11］Zastrow RL. Root cause analysis in infusion nursing: applying quality improvement tools for adverse events［J］.Journal of Infusion Nursing : the Official Publication of the Infusion Nurses Society, 2015, 38 (3): 225-230.
［12］滕苗，肖明朝，吕富荣，等. 什么是RCA2［J］.中国卫生质量管理, 2016, 23 (2): 16-18.
［13］朱腾,戴晓娜,陈水红. 患者安全目标:加强医务人员之间有效沟通的管理策略［J］.中国卫生质量管理,2020,27(6):13-16.
［14］Syyrila T,Vehvilainen-Julkunen K, Harkanen M. Communication issues contributing to medication incidents: mixed-method analysis of hospitals' incident reports using indicator phrases based on literature［J］.Journal of Clinical Nursing, 2020, 29 (13-14):2466-2481.
［15］Palmero D, Di Paolo ER,Stadelmann C,et al. Incident reports versus direct observation to identify medication errors and risk factors in hospitalised newborns［J］.European Journal of Pediatrics,2019,26:259-265.
［16］贾英雷,朱硕斌,林 箐,等.基于管理视角的患者参与患者安全策略研究［J］.中国医院管理,2021,41(3):54-58.
［17］朱丽艳,姜武佳.噪音管理在人性化医院环境建设中的现状调查及处理策略［J］.当代护士（下旬刊）,2021,28(1):40-42.
［18］白彩颖,丁晓华,游文平,等.儿科病区噪声暴露现状调查［J］.护理学杂志,2020,35(16):68-70.［19］Lazarus H. New methods for describing and assessing direct speech communication under disturbing conditions［J］.Environment International, 1990, 16(4-6):373-392.
［20］刘艳丽,刘勇,叶翠梅,等. 双人查对制度对降低门诊给药错误发生率的效果分析［J］.泰山医学院学报,2020, 41 (8): 639-640.
［21］杨瑞芬, 程华.用药错误事件的原因分析及对策［J］.中国继续医学教育, 2020, 12 (26):190-194.
［22］谭然,曹英娟,郭卫婷,等. 国内护士给药错误相关研究的计量分析与对策［J］.护理研究,2019, 33 (15):2663-2670.
［23］佚名.中国医院协会患者安全目标(2019版)之正确识别患者身份［J］.中国卫生质量管理, 2019, 26 (5):37.
［24］Canady VA.Joint Commission announces new national patient safety goal［J］.Mental Health Weekly,2018, 28 (46):5.
［25］王宏琴. 住院患儿身份识别方式及流程的探讨［J］. 护理实践与研究，2020, 17 (7):126-128.
［26］Amanda P, Bettencourt, Mat thew D, et al. Nurse staffing, the clinical work environment, and burn patient mortality［J］.Journal of burn Care and Research : Official Publication of the American Burn Association, 2020, 41(4):796-802.
［27］徐奕旻,吴瑛,张艳,等.全国医院护士人力资源现状的调查［J］.中华护理杂志,2016,51(7):819-822.
［28］代琳琳,侯丹.产后返岗护士工作适应的研究进展［J］.护理管理杂志,2019,19(2):125-128.
相似文献/References:
[1]周新歌,孙琳,徐佳,等.患者安全评价指标体系研究[J].中国卫生质量管理,2015,22(06):064.
[2]陈秋霞 艾慧坚 滕苗 刘剑 肖明朝.国家报告和学习系统的发展与启示[J].中国卫生质量管理,2017,24(03):113.[doi:10.13912/j.cnki.chqm.2017.24.3.37]
[3]修燕 杨圆圆 何萍 温浩.基于信息系统的临床用药闭环管理[J].中国卫生质量管理,2018,25(02):074.[doi:10.13912/j.cnki.chqm.2018.25.2.24]
[4]杨巧 郑双江 陈登菊 肖明朝.应关注患者安全事件中第二受害者的支持需求[J].中国卫生质量管理,2018,25(03):038.[doi:10.13912/j.cnki.chqm.2018.25.3.13]
[5]薛嵋 郭小璐.日间化疗中心的护理安全管理实践[J].中国卫生质量管理,2018,25(04):035.[doi:10.13912/j.cnki.chqm.2018.25.4.11]
[6]唐文凤 蒋迎九 别梦军 肖明朝 赵庆华.一起PICC导管断裂的安全警示[J].中国卫生质量管理,2018,25(04):064.[doi:10.13912/j.cnki.chqm.2018.25.4.21]
[7]李跃荣 易凤琼 闵苏 赵庆华 肖明朝.手术部位标识错误的案例解析[J].中国卫生质量管理,2018,25(05):052.[doi:10.13912/j.cnki.chqm.2018.25.5.17]
[8]应千山 罗琳娜 朱玲凤 朱琳鸿 季一鸣 罗文达 徐颖鹤 缪滔 马宗庆 陈海啸.从错误中学习并成长:台州恩泽医疗中心的实践[J].中国卫生质量管理,2019,26(01):049.[doi:10.13912/j.cnki.chqm.2019.26.1.16]
[9]归纯漪 孙梅.上海市某三甲专科医院医疗风险相关事件调查分析[J].中国卫生质量管理,2019,26(02):053.[doi:10.13912/j.cnki.chqm.2019.26.2.17]
[10]李梦玲 王富兰 肖明朝 赵庆华 沈馨 江颖.1例给药错误的根本原因分析[J].中国卫生质量管理,2019,26(02):058.[doi:10.13912/j.cnki.chqm.2019.26.2.18]
[11]滕苗,肖明朝,吕富荣,等.什么是RCA2[J].中国卫生质量管理,2016,23(02):016.[doi:10.13912/j.cnki.chqm.2016.23.2.06]
[12]张金凤李赛银罗军萍曾纪荣
李梦莹温见炳.RCA2在住院患者中药煎剂发药错误事件中的应用[J].中国卫生质量管理,2020,27(04):066.
ZHANG Jinfeng,LI Saiyin,LUO Junping,et al.Application of RCA2 Method in the Event of an Inpatient Error in Dispensation of Traditional Chinese Medicine Decoction[J].Chinese Health Quality Management,2020,27(01):066.
[13]王道晓陈锦陈萍周俊黄彩英莫彩云冯丹柏杨.基于RCA2的一例下肢PICC置管穿刺鞘断裂事件持续改进[J].中国卫生质量管理,2022,29(09):043.[doi:10.13912/j.cnki.chqm.2022.29.9.10
]
Wang Daoxiao,Chen Jin,Chen Ping.Continuous Improvement of a Lower Limbs PICC Catheterization Sheath Rupture Event Based on RCA2[J].Chinese Health Quality Management,2022,29(01):043.[doi:10.13912/j.cnki.chqm.2022.29.9.10
]
[14]张茜 王艳娇 王诗瑜 邢海英 李庆印.1例先天性心脏病术后患儿因怀抱致低温烫伤事件的根因分析[J].中国卫生质量管理,2024,31(09):024.[doi:10.13912/j.cnki.chqm.2024.31.9.05]
ZHANG Qian,WANG Yanjiao,WANG Shiyu.Root Cause Analysis of a Child with Embrace Hypothermia Scald after Congenital Heart Disease Operation[J].Chinese Health Quality Management,2024,31(01):024.[doi:10.13912/j.cnki.chqm.2024.31.9.05]