FOCUS-PDCA循环降低药品接近错误发生率效果与分析

FOCUS-PDCA Cycle in Reducing the Incidence of Proximity Medication Errors

目的降低药品接近错误发生率,提高患者用药安全。方法运用FOCUS-PDCA循环方法、柏拉图及雷达图等质量管理工具,成立持续质量改进(CQI)小组,调查门诊和住院药品接近错误发生实际情况,分析门诊和住院环节发生药品接近错误的原因,拟订改进方案并组织实施。结果门诊发生药品接近错误的主要原因是药品储存条件不达标和药品调剂不规范,住院发生药品接近错误的主要原因为病区给药流程及时机不合理、药品储存条件不达标;门诊和住院药品接近错误发生率分别由干预前的17. 78%和113. 01%降至干预后的9. 05%和58. 94%(P <0. 05);CQI小组成员的积极性、责任心、自信心、沟通能力、团队协作意识、解决问题的能力也得到提高。结论 FOCUS-PDCA循环可有效降低药品接近错误发生率,促进患者用药安全,增强团队凝聚力,提升医疗服务质量。

Objective To reduce the incidence of proximity medication errors and improve the medication safety. Methods With the FOCUS-PDCA cycle and quality management tools such as brainstorming,Plato and radar chart,through the discovery of problems,the establishment of continuous quality improvement( CQI) team,the actual situation of proximity medication errors in the outpatient and inpatient were investigated,and the causes of the proximity medication errors had been analyzed,then a plan was performed to propose countermeasures. Results The unstandardized drug storage conditions and drug dispensing process were the main causes of the proximity medication errors in outpatient. The unreasonable process and timing of drug delivery,unstandardized drug storage conditions,were the major causes of the proximity medication errors in inpatient. After intervention,the incidence of proximity medication errors in outpatient and inpatient were decreased significantly from 17. 78% and 113. 01% to 9. 05% and 58. 94%( P < 0. 05). In addition,the enthusiasm,responsibility,self-confidence,communication skills,teamwork awareness,and problem-solving ability of CQI team members had also been improved. Conclusion The FOCUS-PDCA cycle can reduce effectively the incidence of proximity medication errors,improve medication safety,enhance team cohesion and promote the quality of medical services.