我院静脉用药调配中心成品输液问题原因分析及对策

Cause analysis and measures in finished product infusion problems of pharmacy intravenous admixture service of our hospital

目的:统计分析2010年3月1日—2016年6月25日临床反馈的静脉用药调配中心(PIVAS)调配的成品输液问题的原因,以便采取针对性措施,提高成品输液质量,确保患者静脉用药安全。方法:分析PIVAS"输液质量问题及输液后不良反应分析处理"登记本记录的临床反馈的36例成品输液问题原因,并针对具体原因采取不同的对策。结果:36例成品输液问题无一例输液反应。药品不良反应(ADR)(包括医嘱不当等导致者)23例,占63.89%;药品质量问题4例,占11.11%;护士输注操作不当问题3例,占8.33%;其他如医嘱、调配操作、患者自身因素各1例;不明原因3例。结论:PIVAS的建立确实可提高输液质量。除不良反应外,PIVAS应从以下三个环节减少成品输液问题:加强医嘱审核,避免不合理医嘱进入调配环节;加强药品管理,确保药品质量,加强药师对成品输液性状的核对与渗漏的检查,杜绝不合格成品输液送至临床;在成品输液标签上设计警示性标注,提醒临床护士在输注前及输注过程中规范操作,从而确保静脉输液质量及患者静脉用药安全。

Objective： To statistically analyze causes of finished product infusion problems from clinical feedback,which were dispensed in pharmacy intravenous admixture service（ PIVAS） in recent six years,in order to take corresponding measures to improve the quality of finished product infusions and ensure safety of intravenous medication for patients.Methods： A total of 36 cases of causes of finished product infusion problems from clinical feedback were analyzed in PIVAS,which were recorded in registration of ‘infusion quality problems and analytic processing adverse reactions after transfusion＇,and corresponding strategies were adopted on the basis of specific causes.Results： There were 36 cases of finished product infusion problems,with no transfusion reaction.Among these,there were 23 cases of adverse drug reactions（ ADR）（ including irrational medical orders,etc.leading to）,accounting for 63.89%; 4 cases of drug quality problems,accounting for 11.11%; 3 cases of improper infusion operation by nurses,accounting for 8.33%; there was each one case in each group,such as the doctor＇s orders,dispensing operation and patient＇s own factors; 3 cases of unexplained problems.Conclusion： The establishment of PIVAS could undoubtedly improve the quality of infusion.In addition to ADR,finished product infusion problems were reduced as following three links of work in PIVAS： strengthen prescription review to avoid irrational orders continuing to infusion preparation link; strengthen drug management to ensure drug quality; enhance characters check and leakage inspection over finished product infusion by pharmacists to prevent unqualified products from sending to clinical department.Design warning mark on the label of finished product infusions to remind clinical nurses of standardized operations before and during infusions,and thereby ensure the quality of intravenous infusions and safety of intravenous medication for patients.