4530例静脉药物配置近似错误的分布特点与对策研究

Study on distribution characteristics and countermeasures of approximate errors in intravenous drug allocation in 4530 cases

目的分析静脉药物配置环节近似错误的发生率及分布特点,为完善管理机制,确保输液安全提供依据。方法回顾性分析2017年1月—2018年12月该院静脉药物配置中心4530例近似错误登记资料,按发生时间、药物种类、发生人群及发现人群4个维度进行分类和分析,并探讨对策。结果配置环节共发生近似错误4530例,错误发生率为1.26‰。按发生时间分类:配置前2752例(60.8%)、配置过程中1778例(39.2%);按药物种类分类:配置过程中普通药物1756例(98.76%)、全胃肠外营养16例(0.9%)、抗肿瘤药6例(0.34%);按发生人员分类:排药药师3183例(70.26%)、配置护士1168例(25.78%);按发现人员分类:配置护士3133例(69.16%)、成品复核药师1397例(30.84%)。结论静脉药物经静脉药物配置中心配置,经过多重环节核对,但近似错误仍有一定的发生率,需优化管理机制,提高安全意识,确保成品输液安全。

Objective To analyze the incidence and distribution characteristics of approximate errors in intravenous drug allocation so as to provide references to improve management mechanism and ensure safe infusion.Methods A retrospective analysis was conducted in 4 530 cases of approximate errors with registration data from January 2017 to December 2018 in a Pharmacy Intravenous Admixture Service of the hospital. According to 4 dimensions including the time of occurrence,drug type,the population of occurrence and the population of discovery,this study classifies,summarizes the characteristics and discusses the countermeasures. Results There were a total of 4 530 cases of approximate errors occurring in the stage of allocation,with the error rate of 1.26‰. According to the time of occurrence,2 752 cases(60.8%) occurred before allocation and 1 778 cases(39.2%) were in the process of allocation. According to the type of drugs,1 756 cases(98.76%) of errors happened on common drugs and 16 cases(0.9%) were total parenteral nutrition,and 6 cases(0.34%) were anti-neoplastic agents during the allocation process. According to the incidence of personnel,3 183 cases(70.26%) were pharmacists;1 168 cases(25.78%) were allocation nurses. According to the population of discovery,3 133 cases(69.16%) were allocation nurses;1 397 cases(30.84%) were pharmacists. Conclusion Intravenous drug allocation has been checked through multiple procedures in Pharmacy Intravenous Admixture Service,but there is still a certain incidence of approximate errors,and it is necessary to further optimize the management mechanism,improve the awareness and skills of safe delivery,and ensure the quality of intravenous infusion.