我院静脉用药调配中心的差错分析及预防措施

Error Analysis and Preventive Measures of Pharmacy Intravenous Admixture Services in Our Hospital

目的分析静脉用药调配中心(PIVAS)的差错及预防措施。方法对我院2015年7月—2016年8月发生的静脉用药调配中心差错事件进行汇总。结果共发生差错事件50例,发生差错的类别包括审方差错、摆药差错、贴签差错、调配差错、停医嘱退药差错、成品输液发放差错等,主要集中于摆药差错与贴签差错,与其他差错类别发生率相比,差异有统计学意义,P<0.05;差错发现部门主要集中在PIVAS(内差),相比病区(外差)构成比明显较高,比较组间数据差异显著,P<0.05。结论对PIVAS差错原因进行分析,并采取相应的防范措施有利于提高成品输液质量,促进临床合理用药,减少不必要的差错事件。

Objective To analyze the errors and preventative measures in Pharmacy Intravenous Admixture Services （PIVAS）. Methods The error events occurred in Pharmacy Intravenous Admixture Services of our hospital from July 2015 to August 2016 were summarized. Results A total of 50 error events were identified, including prescription review errors, medicine allocation errors, labelling errors, dispensing errors, drug discontinuation and drug return errors, finished product transfusion errors, mainly focused on the medicine allocation errors and labelling errors which were of statistically significant difference compared with incidence of other errors, P〈0.05. The errors were mainly observed in PIVAS （poor）, the error constituent ratio of which was significantly higher compared to that in the ward （heterodyne）, with significantly different data between groups, （P〈0.05）. Conclusion Analyzing the causes of PIVAS errors and taking corresponding preventive measures are helpful for improving the quality of finished product transfusion, promoting clinical rational drug use, and reducing unnecessary errors.