应用根本原因分析法对我院1例高风险药品医嘱超量致不良事件的管理实践

Management Practice of One Case of Adverse Event Induced by High-risk Drug Overdose in Doctor's Orders by Root Cause Analysis

目的:探讨有效预防药品医嘱超量致不良事件发生的方法,促进患者安全、合理使用药物。方法:采用根本原因分析法(RCA),对我院1例高风险药品医嘱超量致不良事件的发生、发展过程进行回顾性追踪与分析;通过组建事件RCA调查小组,进行主、客观资料收集、过程再现而还原事件;运用鱼骨图工具辨识事件发生的近端原因与根本原因,进而优化相关工作流程,并有效实施。结果与结论:通过RCA发现,医院药品剂量单位管理不规范、各岗位工作人员对高危药品使用缺乏足够的重视是事件最终发生的根本原因。对案例进行RCA可有效协助医院各部门找出工作流程及组织结构上存在的疏漏与风险,进而采取积极可行的措施,从而规避医疗活动中可能发生的失误。

OBJECTIVE：To discuss the effective way to prevent the adverse event caused by drug overdose in doctor＇s orders,and to promote the safe and rational use of drugs. METHODS：Root cause analysis（RCA）method was adopted to trace and analyze the occurrence and development of one case of adverse event caused by high-risk drug overdose in medical orders retrospectively in our hospital. RCA group was organized to collect subjective and objective data,reproduce procedure and restore the event;fish bone diagram tool was used to determine the proximal and root causes,and then optimized the related workflow and put it into action. RESULTS CONCLUSIONS：Through RCA method,It find that the root causes of the event include the management of drug dosage unit in our hospital not normative,and staff on every position paying not enough attention to the high-risk drugs. It shows that the RCA of event can effectively help hospital finding omissions and hidden risks in business process or organization structures,and then carry out feasible countermeasures to avoid possible mistakes in daily medical work.