住院药房自动化单剂量摆药条件下的药疗差错防范

Interventions of medication errors after the implementation of unit-dose automated dispensing machines in inpatient pharmacy

目的有效提高住院患者口服用药的安全性,降低药疗差错风险。方法用Excel表统计和分析我院住院药房2012年7月-12月发生的单剂量口服缺陷医嘱1 696例次。结果缺陷医嘱影响摆药机效率(剂量/单位错误、规格/厂家错误、执行时间与频率次数错误)979例次(57.7%),影响用药安全(医嘱重复、用法用量不正确)717例次(42.3%)。结论采用医嘱单核对分包药品是发现药疗医嘱缺陷不可缺少的环节。通过增强岗位技能培训提高医务人员的审核能力、加强医药护沟通和强化电脑程序可减少缺陷医嘱和不合理用药医嘱数量,是预防药疗差错、提高单剂量口服用药安全性的有效手段。

Objective To Improve inpatient safety of oral drugs,and reduce risk of medication errors. Methods 1 696 oralorder errors caused by prescription and transcription from July to December 2012 were investigated by Excel. Results 979 cases（ 57.7%） reduced the efficiency of unit-dose automated dispensing machines and 717 cases（ 42.3%） affected to inpatients＇ medication safety. Conclusion It is very important that pharmacists should check drugs packaged unit-dose with prescription paper. It is also an effect means to prevent medication errors that continuing training pharmacists＇ skill,intensifying communication with clinics and strengthening information technology systems.