医疗机构手术室用药错误防范指导原则

Guidelines for prevention of medication errors in operating rooms of medical institutions

手术室在药品的使用及管理全过程中存在用药错误风险。手术室用药错误类型包括处方/医嘱开具错误、处方/医嘱传递错误、调剂错误、标签错误、配制错误、给药技术错误、监测错误、药品储存错误和基数药品设置错误等。用药错误的风险因素主要存在于手术室处方开具与传递、药品调剂和分发、给药与监测及药品管理等环节中。手术室用药错误的防范策略包括技术策略(强制和约束策略,实施自动化和计算机化、制定标准化标识和流程、建立审核项目清单)和管理策略(推荐手术药房管理模式、加大临床药学支持力度、手术室内药品分区存放、合理配置人力资源、规范药品养护管理、倡导安全用药文化、加强基于岗位胜任力的专业技能培训等)。本指导原则适用于参与手术室药品使用和管理的所有人员。

There are risks of medication error in the whole process of drug use and management in the operating room.The types of medication errors in operating room include prescription issuing/doctor′s order giving error,prescription/doctor′s order delivery error,drug dispensing error,labeling error,preparation error,drug application technology error,drug monitoring error,drug storage error,essential drug setting error,etc.The risk factors of medication errors in the operation room mainly exist in the links of prescription issuing and delivery,drug dispensing and distribution,drug administration and monitoring,drug management,etc.The prevention strategies of medication errors in operating room include technical strategies(mandatory and constraint strategies,implementation of automation and computerization,development of standardized identifiers and processes,establishment of audit project lists)and management strategies(recommending the management mode of operation pharmacy,increasing the support of clinical pharmacy,storing drugs in different areas in operation room,allocating human resources reasonably,standardizing management of drug maintenance,advocating safe drug use culture,and strengthening professional skills training based on post competency).This guideline is applicable to all personnel involved in the use and management of drugs in the operating room.