我院静脉药物配置中心差错分析及控制措施

Analysis of Errors in the Pharmacy Intravenous Admixture Service and the Countermeasures

目的:为保障临床用药安全,避免药疗差错提供参考。方法:根据药品说明书、《中国药典》、《临床用药须知》等相关规定,对2006～2007年我院静脉药物配置中心出现的各类差错进行分析,并针对性地制定了控制措施。结果:静脉药物配置中心的内差率为0.04%,差错率为0.001%,主要发生在医师医嘱、护士录入医嘱、药师排药、护士配置、成品核对等工作环节。结论:可通过构建完善的质量安全管理体系、提高药师审方能力、加强工作人员的管理、加强核对制度等措施降低差错发生,促进临床合理用药。

OBJECTIVE： To ensure clinical medication safety and avoid medication errors. METHODS： various errors occurred during 2006--2007 in the pharmacy intravenous admixture service of our hospital were analyzed in accordance with drug package inserts, Chinese Pharmacopeia, and Clinical Medication Information, meanwhile the countermeasures were formulated. RESULTS： The ratio of errors in the pharmacy intravenous admixture service was 0.001%, and the internal ratio of errors was 0.04% . The errors occurred mainly in the following steps： medical orders （by doctors）, input of medical orders （by nurses）, arrangement of drugs （by pharmacists）, allocation of nurses, as well as the check of finished products. CONCLUSIONS： By taking the following measures such as constructing consummate quality safety management system, enhancing pharmacists＇ prescription- checking ability, strengthening management on personnel, intensifying checking system etc, the incidence of errors in pharmacy intravenous admixture service can be reduced and the rational clinical medication can be promoted.