电子处方系统药品输入码相关处方错误的案例分析与持续改进

Case Analysis and Continuous Improvement of Drug Input Code Related Prescription Errors in Electronic Prescription System

目的:探讨电子处方系统药品输入码相关处方错误的潜在失效因素及防范策略。方法:对我院2012年1月1日-2017年12月31日监测的用药错误处方开展回顾性研究和再评价,提取药品输入码相关处方错误进行描述性统计分析,结合典型案例对导致药品输入码相关处方错误的系统潜在失效因素进行根因分析。结果:共收集到药品输入码相关处方错误报告64例,占全部处方错误的19.69%,其中98.44%的错误都是由药师发现并拦截;药品输入码相关处方错误潜在失效因素有两类:一是药名相似的易混淆因素,相关处方错误占比76.56%,特点为易识别且可提前防范,干预重点为药师提前评估,合理设计药品输入码,梳理相似药品清单并告知到医师;二是输入码多重关联的易混淆因素,相关处方错误占比为23.44%,特点为不易识别且难以提前防范,干预重点为加强电子处方录入过程中的用药错误动态监测、个案分析和持续改进。结论:关注药品输入码相关处方错误,加强潜在失效因素的监测和评估,对于更好地发挥电子处方系统作用,确保患者安全用药是很有必要的。

Objective: To explore the potential failure factors and preventive strategies of the drug input code related prescription errors in the electronic prescription system. Methods: A retrospective study and re-evaluation of the medication errors monitored from January 1, 2012 to December 31, 2017 in our hospital were carried out, and the drug input code related prescription errors were extracted and carried out through the descriptive statistical analysis. The root cause analysis was used to find out the system potential failure factors of drug input code related prescription errors in conjunction with typical cases. Results: A total of 64 reports of the drug input code related prescription errors were collected, accounting for 19.69% of all prescription error reports in our hospital, of which 98.44% were found and intercepted by pharmacists. There were two types of potential failure factors of drug input code related prescription errors. One was confusing factors of the drug names, accounting for 76.56% of the related prescription errors. The characteristics were easy to be identified and could be prevented in advance. The intervention focuses consisted of adcance assessment of the pharmacist, reasonable design of the drug input code, analyzing the similar drug list and notifying the physician. The other one was the confusing factors of multiple association of the input codes, accounting for 23.44% of the related prescription errors. The characteristics were difficult to be identified or to be prevented in advance. The intervention focuses consisted of strengthening the dynamic monitoring of medication errors in the electronic prescription entry process, case analysis and continuous improvement. Conclusion: It is necessary to be highly alert of the drug input code related prescription errors and to strengthen the monitoring and evaluation of the potential failure factors, in order to play a better role in electronic prescription system and ensure the safe medication of patients.