静脉药物配置中心洁净区的微生物污染控制管理

Analysis of nurses' errors in pharmacy intravenous admixture services and the counter-measures

目的探讨静脉药物配置中心(PIVAS)洁净区微生物污染原因,进一步完善洁净区微生物污染控制程序及相关管理制度。方法2005至2008年,在PIVAS洁净区面积与室内设施不变的情况下,在不同管理要求下每月1次监测紫外线灯辐照强度,对空气、物体表面、工作人员手部、使用中的消毒液进行细菌监测,每半年1次对洁净区相关室间进行洁净度监测(包括尘埃粒子、浮游菌、沉降菌)计数,并将监测结果进行分析、总结,针对存在问题,进一步完善微生物污染控制程序的部分环节,继续追踪考察所有监测数据,判断整改措施是否有效。结果通过完善、落实微生物污染控制程序,紫外线灯辐照强度合格率从78.5%升至95%;空气细菌总数合格率从90%上升至99%。结论该措施能有效预防微生物污染和保障静脉药物配置的安全。

Objective To ensure the safety of pharmacy intravenous admixture and to make a reference for the reduction and avoidance of the medication errors.Methods The errors which were made by the nurses of PIVAS during the time from August 2006 to August 2009 were analyzed in accordance with drug package inserts, Chinese Pharmacopeia, and Clinical Medication Information, meanwhile the countermeasures were formulated.Results The internal ratio of errors in the pharmacy intravenous admixture service was 0.005% and the ratio of errors was 0.003%.The errors occurred mainly in the following steps：unpracticed two-step dilution,the missing marks,confusion of drug specifications, missing medicine as well as the wrong orders of total nutrient admixture（TNA）.Conclusions The nurses of pharmacy intravenous ad- mixture services（PIVAS） must strengthen the study in pharmaceutical knowledge and drug package inserts, strengthen the education in professional ethics,improve the responsibility, correct the bad behavior in order to make the ratio of errors lowest and ensure the drug safety and effectiveness.