医疗机构药品条码技术应用相关用药错误防范指导原则

Guideline for prevention of medication errors related to application of barcode technology in medical institutions

条码技术是在计算机应用和实践中产生并发展起来的一种自动识别技术,已应用到医疗机构药品采购、管理、调配、使用等各个方面,在药品信息核对、药品与患者匹配等重要环节起到了减少人为差错、提高工作效率及减少用药错误的作用。但由于人为操作、技术水平等因素,条码技术在应用过程中也可发生用药错误。为加强医疗机构药品条码技术应用相关用药错误的防范,合理用药国际网络中国中心组临床安全用药组、中国药理学会药源性疾病学专业委员会和药物不良反应杂志社组织药学、护理、信息及管理方面的专家,以《中国用药错误管理专家共识》为依据,历经数次论证,形成本指导原则。与药品条码技术应用相关用药错误可发生在药品入库与出库、药品调配与发放、静脉药品配制、患者给药等环节,风险因素包括系统因素(条码质量受损,条码打印质量差,扫描、打印设备问题,包装问题,系统自身缺陷以及内条码不能实现信息共享等)和人员因素(条码信息维护错误、信息更新不及时、贴错条码、内条码信息量过少、操作失误及执行不当等)。药品条码技术应用相关用药错误的防范策略包括技术策略(强制和约束策略、自动化和信息化,建立完善的复核制度)与管理策略(规章制度、环境与人员)。本指导原则适用于医疗机构中涉及药品条码技术应用和管理的所有医务人员。

Barcode technology is a kind of automatic recognition technology which is produced and developed in computer application and practice.Barcode technology has been widely used in drug purchase,management,dispensing,use and other aspects,and plays an important role in reducing human errors,improving work efficiency,and reducing medication errors in drug information check,information matching of drug and patient,and other important links.However,barcode technology can also lead to medication errors due to human operation,technical level,and other factors during application.In order to strengthen the prevention of medication errors related to the application of drug barcode technology in medical institutions,experts in pharmaceutical,nursing,informational,and management,who were organized by Medication Safety Panel in China Core Group of International Network for the Rational Use of Drugs,Chinese Pharmacological Society Professional Committee of Drug-induced Diseases,and Adverse Drug Reactions Journal Agency,formulate the guideline for prevention of medication errors in application of barcode technology in medical institutions after several argumentation based on the Expert Consensus on Medication Error Management in China.The medication errors related to drug barcode technology may occurred in links of drug storage and delivery,drug dispensing and distribution,intravenous drug admixture,inpatient drug administration,and etc.The risk factors include systematic factors(damaged barcode quality,poor barcode printing quality,scanning and printing equipment problems,packaging problems,system defects,and sharing difficulties of internal barcode information)and human factors(barcode information maintenance error,not timely information update,wrong pasted barcode,too little internal barcode information,operation error,and improper implementation).The prevention strategies for medication errors related to drug barcode application include technical strategies(including enforcement and constraint policies,automation and information,establishment of good checking system)and management strategies(including regulatory framework,environment and personnel).The guideline is formulated for all medical staff involved in the application and management of drug barcode technology in medical institutions.