基于失效模式和效应分析的高锰酸钾外用制剂用药错误风险点研究

Study on risk points of medication errors in potassium permanganate external preparation by failure mode and effect analysis

目的利用失效模式和效应分析(FMEA)法探讨高锰酸钾外用制剂在临床使用中存在的用药错误风险点。方法在北京和睦家医院和北京妇产医院建立高锰酸钾外用制剂用药错误防范策略研究组,通过查阅文献,问卷调查和实地考察收集失效模式和风险点,对其严重程度(S)、发生频率(O)和发现指数(D)进行评分,确定风险优先级数(RPN),以RPN评分>150为高风险点,制订防范措施。结果根据文献报道,高锰酸钾外用制剂用药错误发生的主要环节是患者使用过程,主要场所是在患者家中。经过综合评价,发现在高锰酸钾外用制剂流通环节中医师处方,药师调剂,护士给药和患者使用这6个环节中存在20个风险点,其中9个风险点RPN>150:(1)外用药片与口服药片相似,患者容易误服;(2)药品包装上没有仅供外用和需要稀释后外用的醒目提示;(3)高浓度的外用药片或药粉可直接接触到皮肤;(4)指导药品稀释浓度以颜色为标准;(5)沟通不充分,患者不知道如何使用药物;(6)未清楚地告诉患者用药方法及注意事项;(7)医院信息系统未提示药品稀释方法;(8)处方未备注稀释浓度;(9)患者使用过程中身体或衣物被染色。结论利用FMEA法可以有效找出高锰酸钾外用制剂临床使用中存在的用药错误风险点,帮助医疗机构制订防范措施,保证患者用药安全。

ObjectiveTo explore the risk points of medication errors of potassium permanganate external preparation in clinical application using Failure Mode and Effect Analysis (FEMA) method.MethodsA study group on prevention strategies of medication errors in potassium permanganate external preparation was set up in Beijing United Family Healthcare and Beijing Obstetrics and Gynecology Hospital. Failure modes and risk points were collected through literature review, questionnaire survey and on-the-spot investigation. Severity (S), frequency of occurrence (O), and likelihood of detection (D) of the failure modes and risk points were scored and their risk priority numbers (RPN) were determined. Failure modes and risk points with PRN scores >150 were defined as high risk points and corresponding prevention strategies were formulated.ResultsAccording to the literature reports, medication errors in potassium permanganate external preparation occurred mainly in the link of patient medication, and the main place was the patient′s home. After comprehensive evaluation, a total of 20 risk points in 6 circulation links (physician prescription, drug dispensing, medication administration by nurses, and patient medication) of potassium permanganate external preparation were found, of which 9 risk points were with RPN>150. They were as follows:(1) the potassium permanganate external tablets looked similar to the oral tablets and were easy to be taken orally by mistake;(2) there were no striking tips of "For External Use Only" and "External Use After Dilution " on drug packages;(3) high concentrations of external tablets or powder could be directly exposed to skin;(4) drug dilution concentration was guided by solution color;(5) patients did not know how to use the drug due to inadequate information communication;(6) failure to clearly inform patients how to use potassium permanganate external preparation and the precautions;(7) hospital information system did not remind the drug dilution method;(8) target concentration after dilution was not noted in the prescription;(9) the patient′s body or clothing might be dyed during medication.ConclusionFMEA method could effectively identify risk points of potassium permanganate external preparation in clinical application, help medical institutions formulate management strategies, and guarantee the medication safety in patients.