19例门诊输液给药错误的原因分析及防范对策

Cause Analysis and Preventive Measures of 19 Out-patient Transfusion Medication Errors

目的:分析门诊输液中护士发生给药错误的相关因素及原因,为医院护理管理者提供防范给药差错的管理依据,减少用药错误的发生。方法:收集门诊输液室2016年6月-2019年6月发生的给药错误19例进行回顾性分析,通过绘制柏拉图、折线图等,找出给药错误发生的主要原因,并提出防治措施。结果:导致19例给药差错发生的主要原因有给药技术性错误、患者身份识别错误及剂量错误。从事临床护理工作3年内的护士因工作经验不足,发生给药错误的概率越大;工作3年以上的护士随着工作年限的增长、风险意识的提高,出现给药错误的概率呈下降趋势。中午时间段12:00-14:30护士人手安排相对薄弱,且护士容易出现身体疲劳,发生给药错误的概率最高。结论:门诊输液中出现给药错误的主要原因有未严格按照药物说明书进行操作、未严格执行三查七对制度、受到外界环境干扰(工作连续性受到外界影响而中断)。医院需要完善管理及支持系统,并且有效执行三查七对制度、交接班制度、优化排班制度等,以减少门诊输液中给药错误的发生。

Objective:To analyze the related factors and causes of medication errors among nurses in outpatient transfusion,so as to provide management basis for hospital nursing managers to prevent medication errors and reduce the occurrence of medication errors.Method:Nineteen medication errors in outpatient infusion room from June 2016 to June 2019 were collected and analyzed retrospectively.The main causes of medication errors were found out by drawing plato and line chart,and preventive measures were put forward.Result:The main causes of 19 drug errors were technical errors,patient identification errors and dose errors.Nurses who had worked in clinical nursing for three years were less likely to make errors because of their lack of working experience.With the increase of working years and risk awareness,the probability of errors in drug administration was declining for nurses who had worked for more than three years.Nurses’s taffing arrangement was relatively weak between 12:00 to 14:30 noon,and nurses were prone to physical fatigue,and the probability of medication errors was the highest.Conclusion:The main reasons for errors in administration in outpatient transfusion include not strictly following the instructions of drugs,not strictly implementing the three checks and seven pairs system,and being disturbed by external environment(work continuity is interrupted by external influence).Hospitals need to improve management and support systems,and effectively implement the three checks and seven pairs system,shift handover system,and optimize the scheduling system,so as to reduce the occurrence of errors in outpatient transfusion.