我院静脉用药调配中心差错分析及防范措施

Analysis of Mistakes and Preventive Measures in PIVAS of Our Hospital

目的:减少静脉用药调配中心(PIVAS)运行中差错的发生,提高静脉用药调配质量,保证临床用药安全、有效。方法:对我院PIVAS 2013年1-4月工作流程中各个环节出现的差错进行原因分析,并制订防范措施,比较改进前、后(2013年5-8月)差错率。结果:通过改进和细化工作流程,分别针对审方、分签、贴签、排药、配制、退药、复核及打包等各环节制定了相应的防范措施并进行了改进。与改进前比较,差错率显著降低,由0.079%下降至0.037%。结论:通过分析差错发生原因并制定相关防范措施可减少差错发生,提高临床用药安全。

OBJECTIVE： To reduce mistakes occurred in pharmacy intravenous admixture service （PIVAS）, improve the quali- ty of intravenous drug admixture, and ensure safe and effective clinical drug use. METHODS： The reasons for mistakes occurred in the working process of each process in PIVAS of our hospital during Jan.-Apr. in 2013 were analyzed to make preventive measures. The rate of mistakes were compared before and after improvement （May-Aug. in 2013）. RESULTS： By improving and refining workflow, the corresponding preventive measures were made and improved for each process, such as checking prescription, classify- ing label, labeling, arranging drugs, preparing drugs, returning drug, rechecking and packaging. Compared with before improve- ment, the rate of mistakes decreased significantly, decreasing from 0.079% to 0.037%. CONCLUSIONS： The analysis of the reasons for mistakes and making preventive measures can reduce the occurrence of mistakes and improve the safety of drug use in the clinic.