基于等级医院评审标准规范管理科室备用药品的实践

The practice of standardizing the management of standby drugs based on the hospital accreditation standards

目的结合三级综合医院评审标准,规范科室备用药品管理。方法药事管理委员会于2015年3~12月运用3个周期PDCA循环管理方法对湖北省十堰市太和医院83个科室备用药品种类、分类、标识、贮存、使用、记录和领取进行质量持续改进。结果统一了全院急救药品的品种、基数和定位贮存,全院备用药品种类减少了54.63%;贮存数量显著减少,其中注射剂减少了65.42%;医务人员每次检查备用药品耗时缩短了63.28%;在第3周期PDCA检查中达到"备用药品管理质量合格率100%"的管理目标;在等级医院评审中受到专家高度赞扬。结论在等级医院评审安全理念指导下应用PDCA循环法,规范管理科室备用药品,提升了管理效能,保障备用药品使用安全性与及时性,降低了医院的成本,值得在临床实践工作中推荐。

Objective To standardize the management of standby drugs based on the accreditation standards for class III comprehensive hospital. Methods Three rounds of PDCA cycle management was applied to constantly improve drug classification, identification, storage, usage, record and claim of standby drugs among 83 departments of Shiyan Taihe Hospital under the instruction of the Pharmaceutical Affairs Board from March to December in 2015. Results The types, amounts and storage positions of the first-aid medicine were unified. The types was decreased by 54.63%; the storage was significantly reduced, among which the injection was reduced by 65.42%; and the inspection time of stand- by drugs by the medical staffs was reduced by 63.28%. During the third round of PDCA evaluation, the eligible rate of standby drugs was 100%, which was highly praised by the evaluation experts in the hospital accreditation. Conclusion It has been proved that by applying PDCA cycle management under the safety guidance of hospital accreditation can help to improve the management efficiency and guarantee the safety and speediness of standby drugs, reduce the man- agement cost of hospital. Therefore, in clinical practice PDCA cycle management is highly recommended.