应用FMEA方法降低我院PIVAS退药归位差错率

发布时间：2018-01-24 21:34

本文关键词： 失效模式与效应分析静脉用药集中调配中心风险评估退药归位差错　出处：《中国药房》2017年28期 　论文类型：期刊论文

【摘要】：目的:降低静脉用药集中调配中心(PIVAS)退药归位差错率。方法:应用失效模式与效应分析(FMEA)方法,以风险优先(RPN)值评估PIVAS退药归位环节中潜在的失效模式,并探讨该环节可能造成差错的原因,提出降低退药归位差错率的可行性方案,并评价实施3个月后的干预成效。结果:在PIVAS退药归位环节中共找出未严格执行双人核对制度(RPN值为100)、不熟悉"看似"药品(RPN值为36)、退药数量多(RPN值为20)等8项高风险失效模式。据此制定了严格执行双人核对制度、优化PIVAS管理系统等相应的风险管控措施。经过3个月的干预管理后,前3项的RPN值分别降为20、16、8,退药归位差错率由1.98%降低为0.62%(P0.05)。结论:我院PIVAS应用FMEA方法,降低了退药归位差错率。
[Abstract]:Objective: to reduce the error rate of drug withdrawal and return in central intravenous drug dispensing center (PIVAS.Methods: the method of failure mode and effect analysis was used to analyze FMEA). To evaluate the potential failure mode in PIVAS return link with the value of risk first, to discuss the possible causes of errors in this link, and to put forward a feasible scheme to reduce the error rate of drug return and return. The effect of intervention after 3 months was evaluated. Results: the results showed that the double check system was not strictly carried out in the return of PIVAS and the RPN value was 100). It is not familiar with 8 high-risk failure modes, such as "seemingly" drugs with a RPN value of 36 渭 and a large number of drug returns with a RPN value of 20). Based on this, a strict double check system has been established. Optimization of PIVAS management system and other corresponding risk management measures. After 3 months of intervention management, the RPN of the first three items were reduced to 20 / 16 / 8 respectively. The error rate of drug return was reduced from 1.98% to 0.62P 0.050.Conclusion: FMEA method is used in PIVAS of our hospital to reduce the error rate of drug return and return.
【作者单位】：泰山医学院附属医院药剂科;
【分类号】：R95
【正文快照】： *主管护师。研究方向:静脉用药集中调配管理。电话:0538-6231018。E-mail:lmh02.good@163.com失效模式与效应分析(Failure mode and effect analy-sis,FMEA)方法是一种前瞻性预防安全隐患的分析方法,由失效模式和效应分析两部分组成。失效模式是指能被观察到的错误和缺陷(俗称

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