基于人机料法环方法的住院药房易混淆药品管理与差错分析

Management and Error Analysis of Easily-Confused Drugs in Inpatient Pharmacy Based on the 4M1E Method

目的提高医院易混淆药品管理水平。方法基于人机料法环(4M1E)方法,从药房工作人员、药房机器设备、药品相关物料、药房规章制度、药房区域环境5个方面分析、制订并实施管理策略。统计北京大学第三医院住院药房易混淆药品2018年3月至12月(实施前)、2019年3月至12月(实施后)发生的差错事件,并比较易混淆药品调剂差错数占调剂医嘱总数的比例。结果实施前易混淆药品差错事件占比为0.011‰(56/5100454),实施后易混淆药品差错事件占比为0.006‰(32/5161277),组间比较差异显著(P<0.05)。结论4MIE方法用于易混淆药品的管理,可降低易混淆药品差错占比,保证患者用药安全,提升药学服务质量。

Objective To improve the management level of easily-confused drugs in hospitals.Methods Based on the man-machine-material-method-environment(4M1E)method,the management strategies were analyzed,formulated and implemented from the five aspects of pharmacy staff,pharmacy machinery and equipment,drug-related materials,pharmacy rules and regulations,and pharmacy regional environment.Error events of easily-confused drugs in the inpatient pharmacy of the Peking University Third Hospital were counted from March to December 2018(before implementation)and from March to December 2019(after implementation),and the proportion of dispensing errors of easily-confused drugs to the total number of dispensing orders before implementation and after implementation was compared.Results Before implementation,the proportion of error events of easily-confused drugs was 0.011‰(56/5100454),which was significantly different from 0.006‰(32/5161277)after implementation(P<0.05).Conclusion The application of 4MIE method in the management of easily-confused drugs can reduce the error proportion of easily-confused drugs,ensure the medication safety of patients,and improve the quality of pharmaceutical care.