应用FMEA方法降低我院PIVAS退药归位差错率

Reduction Error Rate of Homing the Withdrawn Drugs in PIVAS of Our Hospital by Using FMEA

目的:降低静脉用药集中调配中心(PIVAS)退药归位差错率。方法:应用失效模式与效应分析(FMEA)方法,以风险优先(RPN)值评估PIVAS退药归位环节中潜在的失效模式,并探讨该环节可能造成差错的原因,提出降低退药归位差错率的可行性方案,并评价实施3个月后的干预成效。结果:在PIVAS退药归位环节中共找出未严格执行双人核对制度(RPN值为100)、不熟悉"看似"药品(RPN值为36)、退药数量多(RPN值为20)等8项高风险失效模式。据此制定了严格执行双人核对制度、优化PIVAS管理系统等相应的风险管控措施。经过3个月的干预管理后,前3项的RPN值分别降为20、16、8,退药归位差错率由1.98%降低为0.62%(P<0.05)。结论:我院PIVAS应用FMEA方法,降低了退药归位差错率。

OBJECTIVE：To reduce the error rate of homing the withdrawn drugs in pharmacy intravenous admixture service（PIVAS）. METHODS：Using risk priority（RPN）,the potential failure modes for links of homing the withdrawn drugs in PIVAS were evaluated by using failure mode and effects analysis（FMEA） method. Combining with the links of homing the withdrawn drugs,the reasons for errors were investigated,the feasible scheme to reduce error rates was proposed and the intervention effect was evaluated after 3 months. RESULTS：In the PIVAS links of homing the withdrawn drugs,8 high-risk failure modes had been found in total,such as poor double check system（RPN was 100）,unfamiliarity of seemingly drugs（RPN was 36）,a large number of the withdrawn drugs（RPN was 20）,etc. Thus,risk control measures had been formulated,including reinforcing the double check system,optimizing the management system of PIVAS and so on. After 3 months of intervention management,RPN of the first 3 items were reduced to 20,16,8;error rate of homing the withdrawn drugs was reduced from 1.98% to 0.62%（P〈0.05）.CONCLUSIONS：The application of FMEA management method in PIVAS of our hospital has reduced the error rate of homing the withdrawn drugs.