SHEL模型在降低住院药房药品调剂差错中的应用

Application of the SHEL Model in Reducing Drug Dispensing Errors in Inpatient Pharmacy

目的:探讨SHEL模型对降低住院药房药品调剂差错率的效果,为寻找药品调剂差错发生原因提供参考模型,为后期制定防范措施奠定基础。方法:选取2019年6~8月我院住院药房调剂药品条目数3030402条作为对照组,通过SHEL模型对出现调剂差错的原因进行分析并制定相应措施进行干预;干预措施实施1年后,选取2020年7~9月我院住院药房调剂药品条目数3435975条作为观察组,比较干预前后两组药品调剂差错率。结果:我院住院药房2019年6~8月共发生药品调剂差错事件数489条,差错率为0.161‰,2020年7~9月共发生药品调剂差错事件数118条,差错率为0.034‰,两组差异有统计学意义(χ^(2)=276.797,P<0.001)。SHEL模型分析结果显示,药品调剂差错主要由硬件(设备与工作场所)、软件(人员素质与能力等)以及工作环境因素引起。结论:通过SHEL模型分析住院药房药品调剂差错发生的原因,并制定相应改进措施,可以有效减少住院药房药品调剂差错的发生。

Objective:To discuss the effect of SHEL model on reducing drug dispensing errors in inpatient pharmacy,and to provide a reference model for finding the causes of drug dispensing errors and formulating preventive measures.Methods:A total of 3030402 items of drug dispensed in the inpatient pharmacy of our hospital from June to August in 2019 were selected as the control group.The SHEL model was used to analyze the causes of dispensing errors and the corresponding measures were taken to intervene.1 year after intervention,3435975 items of drug dispensed in the inpatient pharmacy of our hospital from July to September in 2020 were selected as the observation group,and the error rate of drug dispensing was compared between the two groups.Results:A total of 489 drug dispensing error events occurred in June to August 2019,with an error rate of 0.161‰.In July to September 2020,a total of 118 drug dispensing error events occurred,with an error rate of 0.034‰.The difference between the two groups was statistical significant(χ^(2)=276.797,P<0.001).The SHEL model analysis results showed that drug dispensing errors were mainly caused by hardware(equipment and workplace),software(personnel quality and ability),and work environment factors.Conclusion:Using SHEL model to analyze the causes of drug dispensing errors in the inpatient pharmacy,and to develop corresponding improvement measures,can effectively reduce the occurrence of drug dispensing errors in the inpatient pharmacy.