应用HFMEA法促进肝素钠注射液在儿童用药中的安全管理

发布时间：2018-06-26 08:27

本文选题：肝素钠注射液 + 儿童患者　；参考：《中国药房》2017年34期

【摘要】：目的:促进肝素钠注射液在儿童用药中的安全使用。方法:应用医疗失效模式与效果分析法(HFMEA),通过文献检索、问卷调查、实地考察等方法,筛选肝素钠注射液在儿童用药过程中的失效模式,并针对这些失效模式制订防范策略并实施,再通过比较实施前、后差错率和风险优先级数(RPN)值评分评价实施效果。结果:通过RPN值评分共获得5项需立即干预的肝素钠注射液用药风险点,包括处方开具时肝素钠注射液给药剂量错误、药品调剂时药师不清楚肝素钠注射液用量的计算方法、护理给药时未执行输注前双人核对流程等。经制订并实施相应的防范策略后,肝素钠注射液相关差错由实施前的8例减少到1例,差错率由3.76%降低到0.51%(P0.01);5项失效模式的RPN值分别由112.08、91.56、115.78、94.52、99.23下降到28.02、23.91、27.71、23.63、20.55。结论:应用HFMEA可前瞻性地对肝素钠注射液儿童用药环节进行系统的分析,再结合本院的实际情况制订并实施对应的防范策略后,可减少肝素钠注射液使用中的相关差错,促进儿童用药安全。
[Abstract]:Objective: to promote the safe use of heparin sodium injection in children. Methods: the medical failure mode and effect analysis (HFMEA) was used to screen the failure mode of heparin sodium injection in the course of drug use in children by means of literature retrieval, questionnaire investigation and field investigation. According to these failure modes, the preventive strategies are worked out and implemented, and the implementation effect is evaluated by comparing the error rate and the RPN score before the implementation. Results: five risk points of heparin sodium injection for immediate intervention were obtained by RPN score, including the wrong dosage of heparin sodium injection when prescription was prescribed, and the calculation method of heparin sodium injection dosage was not clear to pharmacists when the drug was adjusted. The double check procedure before infusion was not carried out in nursing administration. The relative errors of heparin injection were reduced from 8 cases to 1 case, and the error rate was reduced from 3.76% to 0.51% (P0.01). The RPN value of 5 failure modes was reduced from 112.08 to 28.0223.91.91,27.71and 23.630.55, respectively. Conclusion: HFMEA can be used to analyze the medication link of heparin sodium injection in children, and to make and implement the corresponding preventive strategy combined with the actual situation of our hospital, can reduce the related errors in the use of heparin sodium injection. To promote the safety of drug use in children.
【作者单位】：山西省儿童医院药剂科;
【基金】：2016年国家卫生和计划生育委员会药政司委托研究课题(No.药政[2016]61号)
【分类号】：R952

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