根本原因分析法用于一例发药出门差错

目的通过对门诊药房一例发药出门差错进行分析,介绍根本原因分析法(Root Cause Analysis,RCA)在医院药学中的应用。方法运用根本原因分析方法回顾性分析我院门诊药房一例发药错误。结果通过一系列的分析找出差错原因并确定根本原因,制定了高危药品管理、查对制度、疑问追访制度等整改措施,对整改效果进行确认。结论根本原因分析法为医院药学管理者提供一种系统的处理差错的科学方法,值得在临床工作中推广。

Objective To introduce how to use a method named Root Cause Analysis to solve problems in the Hospital Pharmacy through the analysis on a medication error . Methods To analyze an medication error happened in the Outpatient by using the method named Root Cause Analysis. Results Dig out the main reason lead to this medication error and made a series of rectification measures, such as the High-alert drug management,system on the check when dispensing, system on the follow-up the possible medication error. We confirmed the effect of the rectification measures. Conclusions The Root Cause Analysis is a scientific method, it is worth promoting in clinical work.