医院用药差错的系统分析与对策

发布时间：2018-01-23 07:33

本文关键词： 用药差错原因分析用药安全防范措施鱼骨图　出处：《中国医院药学杂志》2015年03期 　论文类型：期刊论文

【摘要】：目的:分析某省级三甲医院药疗实践中出现的用药差错情况,提高药学服务水平和药师调剂质量,减少医疗安全隐患,促进医院医疗质量提升。方法:汇总该院2012年9月1日-2013年8月31日出现的用药差错,采用美国国家用药差错报告和预防协调委员会(NCC-MERP)用药差错分级方法进行汇总,分析用药差错产生的原因,提出适当的防范措施和对策。结果:本研究共收集332例用药差错,占总调剂总量的0.11‰。按照不同分类方法汇总分析发现:98.2%(326)的差错未造成患者伤害;内部差错与出门差错比例为291∶41;差错发生率最高的为药师调配数量差错,占到33.4%;鱼骨图分析得出人、事、物为造成调配数量差错的三个主要原因。结论:用药差错是客观存在的,医院应当在建立现代的非惩罚性用药差错事件上报制度上,采取鼓励措施促使医务人员积极自愿上报用药差错事件,并利用质量管理工具全面分析和防范用药差错。
[Abstract]:Objective: to analyze the situation of medication errors in the pharmacotherapy practice of a provincial third class hospital, to improve the level of pharmaceutical care and the quality of pharmacists, and to reduce the hidden danger of medical safety. Methods: to sum up the drug errors occurred in the hospital from September 1st 2012 to August 31st 2013. The causes of drug errors were analyzed by using the NCC-MERP- NCC-MERP- classification method of the National Drug use error report and the Prevention Coordination Committee of the United States. Results: 332 cases of drug errors were collected in this study. According to the analysis of different classification methods, it was found that the error of: 98.22% 326) did not cause injury to the patients. The ratio of internal error to departure error is 291: 41; The highest error rate was the quantity error of pharmacist allocation, accounting for 33. 4%; Fish bone map analysis shows three main reasons for the errors in allocation quantity. Conclusion: drug errors exist objectively and hospitals should establish a modern reporting system of non-punitive drug errors. Encouraging measures should be taken to encourage medical personnel to report drug errors voluntarily, and to use quality management tools to analyze and prevent drug errors.
【作者单位】：山东大学附属省立医院;
【分类号】：R95
【正文快照】： 药物是患者安全事件的一个主要因素[1],用药差错指药物应用过程中可能发生的错误,通常发生在药物选择、处方、调配、标签、包装、发药、服用和监测过程中[2-5]。用药差错是客观存在的,发生原因有个人因素,也可能存在系统或管理方面漏洞。我国《医疗机构药事管理规定》中明确“

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