根本原因分析法在静脉泵泵速调整沟通不足事件中的应用

Application of root cause analysis in inadequate communication in adjusting rate of intravenous infusion pump

目的：通过分析静脉泵泵速调整沟通不足案例，制定改善方案并实施，减少用药错误（ ME）发生。方法利用根本原因分析法（ RCA）分析1例D级ME。步骤如下：组建RCA小组，针对该事件进行资料收集与分析，绘制事件流程图、挖掘事件直接原因，画出鱼骨图、确认根本原因，拟定改善方案。结果确定该事件为“静脉泵泵速调整沟通不足事件”。直接原因为医生与护士沟通不足，缺乏静脉泵泵速调整记录，护士工作负荷大。根本原因为缺乏静脉泵泵速调整执行、记录机制。拟定改善方案：建立并规范静脉泵泵速调整执行、记录机制；引进智能静脉泵，或设计专用泵速调整记录表记录调整过程；加强医务人员对规范和标准流程的学习培训。实施成效：建立了标准操作流程与规章制度，设计了专用泵速调整记录表，要求医生进行调整泵速书面记录且在交接班时须说明，责任护士执行后需签字确认。同时，进行医务人员教育培训，明确职责分工。经过药师后续观察，病房中未再发生类似事件。结论建立标准操作流程与规章制度、引进先进技术、加强对医务工作者的培训教育可减少ME。

Objective To reduce the occurrence of medication error（ ME）by analyzing a case of inadequate communication about the rate adjustment of intravenous infusion pump and making improvable plans and carrying out. Methods An ME case of category D was analyzed using root cause analysis （ RCA）. The steps were as follows：forming an RCA team,collecting and analyzing relevant information on this ME event,drawing flowcharts to mine the direct causes,drawing fishbone diagram to confirm the root causes,and making improvable plans. Results The event was identified as ＂inadequate communication about the rate adjustment of intravenous infusion pump＂. The direct causes included inadequate communication between doctors and nurses,lack of record about the rate adjustment of intravenous infusion pump,and nurses′heavy workload. The root cause was lack of a mechanism of carrying out and recording of the rate adjustment of intravenous infusion pump. The improvable plans contained establishing and standardizing the mechanism of carrying out and recording of the rate adjustment of intravenous infusion pump, introducing intelligent intravenous infusion pump or designing an appropriate record sheet of the rate adjustment of intravenous infusion pump to note the process of rate adjustment,reinforcing learning and training of medical staff on norm and standard procedure. The implement achievements were as follows. Standard procedure and regulatory framework were established,the appropriate record sheet of the rate adjustment of intravenous infusion pump were designed,doctors were asked to implement written statement of the rate adjustment and explain when shift exchange,and the charge nurses were asked to implement signature confirmation after the rate adjustment. Meanwhile,the learning and training of medical staff were carried on to clarify about the roles. After a follow-up observation of pharmacist,the kind of the event did not recur in the wards. Conclusion ME event could be reduced by establishing standardized flow and regulatory framework,introducing advanced technology,and reinforcing learning and training of medical staff.