我院用药差错与临界差错事件分析与整改措施

Analysis and Countermeasures of Medication Errors and Borderline Error Events in Our Hospital

目的:探讨用药差错与临界差错事件发生的原因及对策,为减少医院的用药错误提供依据。方法:基于我院2017年1月至2018年9月不良事件信息平台上报的277例用药差错与临界差错事件的数据汇总,从差错环节、差错类别及差错人三个方面进行数据分析,提出改进措施、减少用药差错。结果:针对导致差错的原因优化系统管理、加强培训、进行PDCA质量改进,持续改进固化流程,修改制度与流程。结论:通过用药差错与临界差错的原因分析及质量改进,有效防范用药差错事件的发生,最大限度减少用药差错,促进临床合理用药,确保患者安全用药。

Objective:To explore the causes and countermeasures of medication errors and borderline error events,so as to provide evidence for reducing medication errors in our hospital.Methods:Based on the data of 277 cases of medication errors and borderline error events reported on the Adverse Events Information Platform of our hospital from Jan.2017 to Sept.2018,analysis was carried out from three aspects such as error link,error category and error person,and improvement measures were put forward to reduce medication errors.Results:According to the causes of errors,the system management was optimized,training was strengthen and PDCA quality was improved with the continuously improvement of solidification process and modification of systems and processes.Conclusion:Analysis of the causes of medication errors,borderline error events and quality improvement can an effectively prevent the occurrence of medication errors,minimize medication errors,promote rational clinical medication,and ensure the safe medication for patients.