我院高警讯药品管理模式的建立及优化

Establishment and Optimization of High-alert Drug Management Mode in Our Hospital

目的:建立我院高警讯药品的安全管理模式,确保临床用药安全。方法:根据《JCI医院评审标准》(第五版)构建我院高警讯药品管理模式,并根据实施效果分析该管理模式存在的问题,然后通过PDCA循环法对其进行优化改善,以"有高警讯药品明确清单、高警讯药品清单与实际储存品种相符、高警讯药品专区专柜存放、高警讯药品交接和使用记录齐全"等10项内容作为考核指标,评价改善后10个月内各科室对各项指标的遵从率。结果:我院制定了高警讯药品的相关管理制度,从其警示及储存、处方/医嘱开具、调配发放等方面进行管理,实施后高警讯药品的管理总体达到了规范、有序,但除药剂科外的其他科室对高警讯药品的管理仍存在不足;运用PDCA循环法改进后,在第8个月,各科室(药剂科除外,下同)对各指标的遵从率均达到100%,与第1个月10项指标的遵从率(40.90%、25.00%、68.18%、40.90%、56.82%、90.91%、36.36%、11.36%、40.90%、45.45%)相比差异具有统计学意义(P<0.05),表明改进有效;第9、10个月各科室对各指标遵从率均为100%,表明改进效果持续稳定。结论:我院高警讯药品的管理正在不断改进提升,可为患者提供更优质的药学服务。

OBJECTIVE:To establish safety management mode of high-alert drugs in our hospital,and to guarantee the safety of drug use in clinic.METHODS:According to the JCI Hospital Appraisal Standard(fifth edition),the management mode of high-alert drugs was established in our hospital.The problems of the management mode were analyzed according to implementation effects.PDCA cycle was used to optimize and improve the mode.The compliance rates of evaluation indicators were evaluated in each department within 10 months after improvement using 10 evaluation indexes,such as“having a clear list of high-alert medications”,“high-alert drug list in line with actual storage varieties”,“setting a special area or counter to store high-alert medications”,“having complete records about delivery and use of high-alert medication”.RESULTS:Through formulating the management system of high-alert drugs,our hospital conducted the management in respects of alerting,storage,prescription/medical order,dispensing,delivery,etc.After implementation,the management of high-alert drugs has been standardized and ordered;except for pharmacy department,there was still existing problems in the management of high-alert drugs in other departments.After using the PDCA cycle,the compliance rates of the 10 indicators in the eighth month had reached 100%(except for pharmacy department,similarly hereinafter);compared with the first month of compliance of 10 index(40.90%,25.00%,68.18%,40.90%,56.82%,90.91%,36.36%,11.36%,40.90%,45.45%),the difference was statistically significant(P<0.05),which indicated effective improvement.The compliance rates of evaluation indicators were 100%in ninth and tenth month,indicating continuous and stable effects.CONCLUSIONS:The management of high-alert drug established in our hospital is constantly improving and upgrading,and can provide better pharmaceutical care for patients.