住院病人静脉药物治疗给药错误环节分析与对策

Analysis and countermeasures of links of intravenous medication errors among inpatients

目的分析住院病人静脉药物治疗过程中发生给药错误的环节,为制订改进措施提供依据。方法回顾性分析某三级甲等医院过去5年护理非惩罚性主动上报静脉药物治疗给药错误环节、给药错误类型及发生给药错误原因。结果静脉药物治疗发生给药错误的环节由高到低依次为:护士给药操作、护士医嘱处理、护士配药、医生开具医嘱、药房配药发药、病人依从性差;发生给药错误涉及护士、医生、药师、病人;给药错误类型为:药物错误、遗漏给药、发错病人等,操作不规范和流程设计不合理是发生给药错误的主要原因。结论由护士失误引起的给药错误所占比例最高,特别是由护士个人完成的环节,给药错误发生率最高;整体理念是研究预防给药错误发生对策的关键,提高护理管理水平,减少给药错误的发生要从多方面考虑。

Objective To analyze the links of intravenous medication errors of inpatients, so as to provide references for making improvement measures. Method Nursing non - punitive reporting intravenous medication error links, error types and the reasons were retrospectively analyzed in a 3A - class hospital in the past 5 years. Results Error links of intravenous medication from high to low were as follows ：The drug action of the nurse, doctor＇s advice, dosage, shifting of duty undone, doctor prescribing medical advice, the pharmacy dispensing drugs, and poor patient compliance. Dosing errors involved nurses, doctors, pharmacists and patients（ patients＂ families）. Error types included medication errors, omission of drugs and wrong dispensing. Unstandard operation and the design problem of the process were the main reasons. Conclusion Medication errors are mainly caused by nursing errors, especially links done by nurses themselves. The overall nursing concept is the key to the study of to prevent medication errors