根原因分析法在靶向药物给药错误分析中的应用

Application of Root Cause Analysis in Targeted Drug Dosing Error

应用根原因分析法分析1例靶向药物给药错误事件的原因,提出整改方案。通过事件调查、直接原因分析,确认根原因为:无自备药物交接流程,配药流程不合理,实习生带教不规范,对护士工作流程与查对制度培训不够。针对原因制定改进措施:制定自备药物交接流程,制定自备药物使用规定,优化配药流程,规范输液贴信息管理,规范实习生管理,加强对护士的培训及检查,对患者进行安全教育,避免类似事件的发生,提高给药安全。

Analyzed the causes of one targeted drug dosing error with root cause analysis and put forward improvement plans. Through investigating and analyzing the direct causes, root causes were identified as absence of autonomous medicine handover process, irrational dispensing flow, substandard practice guiding and insufficient training on nurses for their work flow and check system. Based on the above causes, improvement measures were made and safety education on patients were carried out so as to prevent the occurrence of these errors and improve medication safety.