RCA^2在住院患者中药煎剂发药错误事件中的应用

Application of RCA^2 Method in the Event of an Inpatient Error in Dispensation of Traditional Chinese Medicine Decoction

针对1例住院患者中药煎剂发药错误事件,应用RCA^2进行改进.首先,将患者置于安全的环境下,基于风险的优先等级评估,成立RCA^2团队;然后,寻找事件发生事实,建立因果关系,明确行动方案并监督执行,包括启用信息系统、修订管理制度、优化工作流程等.通过系列举措,防范了此类事件再发生,更好地确保了患者安全.

In response to an error in dispensing Chinese medicine decoction in an inpatient,improvement was made with RCA^2.Firstly,put patient in a safe environment,and set up an RCA^2 team based on risk priority assessment.Then,look for the facts of the incident,establish a causal relationship,define the action plan and supervise the implementation of the action,including the activation of the information system,the revision of the management system,and the optimization of the workflow,etc.Through a series of measures,the recurrence of such incidents was prevented,which better ensured the safety of patients.