清单式互查在护士给药查对习惯培养中的应用

Application of inter-checking by checklist in the development of drug administration checking habits among nurses

目的探讨清单式互查在护士给药查对习惯培养中的应用效果。方法根据给药操作中查对制度落实的关键节点和容易遗漏的环节制作"给药查对清单",护士使用该清单进行为期21 d的互相检查。每周根据检查中存在的主要问题进行原因分析,制定改进措施。科室质控员进行查对制度落实情况检查。结果使用清单互查前,医嘱双人查对、摆药/配药双人查对、操作时携带医嘱执行单、核查患者身份使用开放式提问、使用2种以上的方法核对患者信息、使用PDA扫描患者腕带、操作前中后完整查对、患者有疑问时查询解答的落实率分别为94. 38%、22. 47%、96. 63%、89. 89%、79. 78%、93. 26%、88. 76%、95. 51%,实施21 d互查后落实率分别为100. 00%、95. 69%、100. 00%、98. 28%、97. 41%、100. 00%、96. 55%、98. 28%,其中医嘱双人查对、摆药/配药双人查对、核查患者身份使用开放式提问、使用2种以上的方法核对患者信息、PDA扫描腕带及操作前中后完整查对的落实率互查前后比较,差异有统计学意义(P <0. 05)。结论护士使用"给药查对清单"进行给药操作中的互查,对培养护士良好的查对习惯、保障患者用药安全具有重要意义。

Objective To evaluate the application of inter-checking by checklist in the development of drug administration checking habits among nurses. Methods The head nurse made “medication checklist” according to key issues and weak links of drug administration. Nurses performed the inter-checking by the checklist for 21 days. The main problems in inter-checking were analyzed and corresponding improvement measures were carried out. The quality controller evaluated the implementation the drug administration checking before and after the implementation of inter-checking. Results Before the implementation of inter-checking with the list, implementation rate of double check for physician's orders, double check for dispensing, taking order sheet when operation, identity verification by open-ended question, using two or more methods to check patients' information, the wrist belt scan with PDA, completely check before, during and after operation, timely response to the patients' questions was 94.38%, 22.47%, 96.63%, 89.89%, 79.78%, 93.26%, 88.76%, 95.51%, respectively, and was 100.00%, 95.69%, 100.00%, 98.28%, 97.41%, 100.00%, 96.55%, 98.28% after implementation of inter-checking. There was a significant difference in implementation rate of double check for physician's orders ,double check for dispensing, identity verification by open-ended question, two or more methods to check the patient's information, the wrist belt scan with PDA, completely check before and after implementation of inter-checking(P<0.05). Conclusion Inter-checking with the"medication checklist" was important for the nurses to develop good checking habit of medication,leading to safety of drug administration.