RCA在发药错误不良事件中的应用

Application of RCA in Adverse Events Associated with Drug Delivery Errors

目的探讨根本原因分析法在门诊药房发药错误不良事件的应用,减少发药错误发生。方法回顾性分析医院门诊药房发药错误1例不良事件,通过时间序列表及原因树分析,归纳出发药错误的近端原因,找出根本原因,确立问题为“四查十对”未落实、药品名称相近、特殊人群安全用药意识不足、高峰时段排班不合理、人员沟通不到位,拟定改善策略:严格执行医疗核心制度、加强药学人员培训、定期盘点药品、弹性排班及完善配药流程、高峰时段管理等,并对整改效果进行确认。结果门诊药房实施RCA管理后,通过在系统及过程方面加强质量管理,2019年度未发生发药错误不良事件。结论通过RCA管理可有效减少发药错误不良事件,提高患者的用药安全和满意度。

Objective:To explore the application of root cause analysis in adverse events of dispensing errors in outpatient pharmacy,and reduce the occurrence of dispensing errors.Method:Retrospective analysis of 1 case of adverse event caused by drug delivery error in outpatient pharmacy of hospital was made.With time sequence table and the analysis of reason tree,proximal causes of drug errors were concluded,the root causes were found out and the unimplemented problems of“four checks and ten matches”identified.Improvement strategies for drugs with similar names,insufficient awareness of safe use of drugs in special groups,unreasonable scheduling during peak hours,and insufficient communication among personnel should be formulated.The strategies will cover strict implementation of medical core system,the strengthening of the training for pharmaceutical personnel,regular drug inventory,flexible scheduling,the improvement of dispensing process,peak time management,etc.And the rectification effect should be confirmed.Result:After the implementation of RCA management in outpatient pharmacy,no adverse events occurred in 2019 through strengthening quality management in system and process.Conclusion:Therefore,RCA management can effectively reduce the adverse events of drug delivery errors and improve the safety and satisfaction of patients.