应用Wichens认知模型分析住院药房调剂差错与改进

Analysis and Improvement of Dispensing Errors in the Inpatient Pharmacy by Wichens Cognitive Model

目的应用Wichens认知模型分析调配差错的发生原因,降低调剂差错。方法应用Wichens认知模型设计差错登记表,并分析和改进医院住院药房2016年下半年的差错原因,并与2017年上半年进行对比。结果数量差错中的44%是由信息处理阶段的算错导致,品规差错中的54%是由信息识别阶段的忽略药品信息导致,品种差错中的48%是由信息识别阶段的看错药品信息,42%是由信息执行阶段的包装、位置、药理作用相似所致。整改后,数量差错率由0.17%降为0.13%,品规差错率由0.043%降为0.028%,品种差错率由0.05%降为0.035%,差异均显著(P<0.05)。结论Wichens认知模型有助于分析调配差错的发生机制,基于信息加工角度的改进措施可有效降低调配差错,保证用药安全。

Objective To analyze the causes of dispensing errors by Wichens cognitive model,and to reduce dispensing errors.Methods Wichens cognitive model was used to design the error registration form.The causes of dispensing errors in our inpatient pharmacy in the second half of 2016 were analyzed and improved,and the results were compared with those in the first half of 2017.Results 44%of quantity errors were caused by miscalculation in the information processing phase.54%of varieties and specifications errors were caused by the omission of drug information in the information identification phase.48%of variety errors were caused by misread drug information in the information identification phase and 42%of variety errors were caused by similar packaging,location and pharmacological effects in the information implementation phase.After rectification,the rate of quantity errors was reduced from 0.17%to 0.13%,the rate of varieties and specifications errors was reduced from 0.043%to 0.028%and the rate of variety errors was reduced from 0.05%to0.035%,and the difference was significant(P<0.05).Conclusion Wichens cognitive model is helpful to analyze the mechanism of dispensing errors.The improvement measures based on information processing can effectively reduce the dispensing error and ensure the safety of the medication.