静脉药物配置中心差错管理的实践与探讨

Practice and Discussion of Error Management in Pharmacy Intravenous Admixture Services

目的减少静脉药物配置中心(PIVAS)输液配置差错。方法引入差错管理理念,注重差错预防和差错管理,提倡差错知识共享和无责化管理,改善差错管理氛围。利用帕累托图分析法、鱼骨图分析法等对差错现状及原因进行分析,采取措施持续改进,比较改进前后差错改进效果。结果改进后,差错总例数减少了30.2%,各差错类型中扫描差错例数减少最为显著,其次是溶媒贴错和批次分错。结论通过科学的差错管理手段和管理工具,使PIVAS的流程和制度不断优化,差错得到改善,输液配置质量得到提高,减少了药品浪费,提高配置人员的规范操作意识和工作责任心。

Objective To reduce infusion admixture errors in pharmacy intravenous admixture services(PIVAS).Methods The concept of error management was introduced to emphasize the prevention and management of errors,promote the management of shared knowledge and accountability,and improve the error management atmosphere.The current situation and causes of errors were analyzed by using Pareto-diagram and fishbone diagram to explore measures for continuous improvement,and the effects before and after the measures were compared.Results The total number of errors decreased by 30.2%.Of all the types of errors,scan errors had the most significant decline,followed by the solvent label error and batch error.Conclusion The adoption of scientific error management approaches and tools can optimize the procedures and system of PIVAS,decrease errors,improve the infusion admixture,reduce medication waste,and raise the staff's awareness of standardized operation and responsibility.