根因分析法在难溶性药物配置不良事件中的应用研究

Application of Root Cause Analysis in Adverse Events of Insoluble Medicine Disposition

应用根因分析法分析静脉药物集中调配中心(Pharmacy Intravenous Admixture Services,PIVAS)1起批量难溶性药物配置错误的原因。通过事件调查、原因分析、确定根本原因、制定改进方案4个阶段,认为发生配置错误的根本原因是排药流程、难溶性药物配置流程等存在不合理、组长职责未落实到位、科室固定人员配置不足、对新上岗的护士没有根据本科室的工作特点与工作流程进行系统培训。针对根本原因,重新修订排药及难溶性药物配置流程,完善、落实静脉配置中心仓内护理组长的职责,制定新上岗护士规范性培训计划,以避免类似事件的再次发生,降低PIVAS药物配置错误的发生率,保证患者用药安全。

This study used root cause analysis to analyze the causes of incorrect disposition of a batch of insoluble drugs in Pharmacy Intravenous Admixture Services(PIVAS). Through the investigation of the incident, the analysis of the cause, the determination of the root cause, and the formulation of the improvement plan, the root causes of the incorrect disposition included the unreasonable process of medicine dispensing and insoluble medicine disposition, the implemented responsibilities of team leaders, Insufficient staffing of permanent staff in the department, no systematically training of the work characteristics and work processes for newly-employed nurses. For the root causes, we re-revised the process of medicine dispensing and insoluble medicine disposition, improved and implemented the responsibilities of the leaders of inpatient care center, and developed a new training program for nurses to avoid recurrence of similar events, so that to reduce PIVAS medicine disposition, ensure the safety of patients.