1例给药错误的根本原因分析

Root Cause Analysis of an Adverse Event by Improper Medicine Administration

针对1例给药错误不良事件,成立RCA团队,完成事件回顾性描述,应用鱼骨图查找近端原因,运用五问法剖析根本原因,制定改进措施并落实。通过完善相似药品管理制度,细化口服药给药流程,落实双向核对制度,加强低年资护士培训与管理,可杜绝相似药品口服给药错误事件再发生。

For one case of adverse event by improper medicine administration,the root cause analysis(RCA)team was established to complete the retrospective description of the event,apply the fishbone diagram to find the near-end cause,use the five-question method to analyze the root cause,and formulate improvement measures and implement them.Through the improvement of similar drug management system,the oral drug administration process can be refined,the two-way check system will be implemented,and the training and management of low-grade nurses can be strengthened to prevent the recurrence of oral drug misfeeds of similar drugs.