某儿童医院静脉用药调配中心差错原因分析及改进措施

Error Analysis and Improvement Measures of Pharmacy Intravenous Admixture Services in a Children’s Hospital

目的:总结静脉用药调配中心差错原因,优化管理措施,以提高静脉用药调配中心的工作效率和成品输液质量。方法:调取2016年11月至2018年11月郑州儿童医院东区静脉调配中心调配医嘱,每6个月为一个阶段,共4个阶段对发生差错的原因进行分析总结,采取相应的整改措施,并比较各阶段的差错率。结果:2016年11月至2018年11月共配置成品输液1985574袋,发生差错349袋,差错率0.176‰,其中摆药和加药环节差错出现次数较多。四个阶段的差错率分别为0.314‰、0.253‰、0.152‰和0.063‰,采取改进措施并实施后,差错率呈下降趋势。结论:对静脉用药调配差错原因进行分类总结,提出针对性的改进措施,可显著降低差错率,提高成品输液质量及工作效率。

Objective:To summarize the causes of errors in the pharmacy intravenous admixture services and optimize the management measures,so as to improve the efficiency and quality of finished infusions in pharmacy intravenous admixture services.Methods:From Nov.2016 to Nov.2018,medical orders were extracted from the pharmacy intravenous admixture services of the east district of Zhengzhou Children’s Hospital.Every six months was a phase,and there were four phases in total.The causes of errors were analyzed and summarized,corresponding measures were formulated,and the error rates of each phase were compared.Results:From Nov.2016 to Nov.2018,a total of 1,985,574 cases of finished infusions were configured,with errors occurring in 349 cases and an error rate of 0.176‰,and there were more errors in the placement and dosing sessions.The error rates for the four phases were respectively 0.314‰,0.253‰,0.152‰and 0.063‰.After the improvement measures were taken and implemented,the error rate showed a downward trend.Conclusion:By classifying and summarizing the causes of errors and putting forward targeted improvement measures,the error rates of pharmacy intravenous admixture can be significantly decreased and the quality and working efficiency of the finished infusion can be improved.