肿瘤患者术中给药错误原因分析及预防对策

Analysis of Medication Errors and the Related Preventive Strategies during the Operation for Cancer Patients

目的:分析肿瘤患者术中给药错误的原因并探讨解决的方法。方法:对34起手术室给药错误事件进行回顾性分析。结果:在给药错误发生的手术级别中,三级手术占58.8%,四级手术占35.3%;在给药错误的分类中,给药时间错误占44.1%,其次为遗漏给药占17.6%;在给药错误的药品种类中,抗生素给药造成的错误占73.5%;91.2%的给药错误未对患者造成伤害。在给药错误的人为因素中以人力不足和不遵守操作规程为主要原因,分别占61.8%和17.6%;给药错误的主要人群为工作年限5年以下的低年资护士,占76.5%。结论:加强术中给药管理,合理配备手术室护理人员。加强低年资护理人员用药相关知识和技能的培训以及责任心的培养和职业道德的教育,以减少给药错误事件的发生。

Objective： To analyze the causes and to explore the preventive ways of medication errors during the operation for cancer patients. Methods： Thirtyfour cases of administering errors occurred in the operating room were retrospectively analyzed. Re suits ： Among the 34 cases, 58.8% occurred in the third grade operations and 35.3% in the fourth grade operations. As for the classi fication of theses errors, 44. 1% of the medicine was given in incorrect time, 17.6% was the missed administratering. Antibiotics ad ministratering errors accounted for 73.5% of all errors; 91.2% of the medication errors didn＇ t bring any harm to the patients. Under staffing（61.8% ） and disobeying of the operation procedures （ 17.7% ） were the main causes of human factors. Nurses with working experience fewer than 5 years accounted for 76.5% of the crowds who made the medication administering errors. Conclusion： Medica tion administering errors may be decreased by enhancing the medicine administering management during operation and improving the nnderstaffing status in the hospital. The training of medication related basic knowledge,skill and responsibility as well as the education of professional ethics for the junior nurses should also be emphasized.