住院药房全自动片剂摆药机差错分析与措施改进

Error Analysis and Measure Improvement of Automatic Tablet Dispensing Machine in Inpatient Pharmacy

目的通过对医院住院药房全自动口服片剂摆药机摆药差错的回顾性分析,提出改进措施,降低口服单剂量摆药差错率。方法统计2020年8月~12月的差错数据,归纳分析差错原因及对应的解决措施。结果总差错数为134例,差错类型分为:药品缺损及出现碎片(84例),药品数量错误(34例),药品串包(14例),人为差错(2例)。结论全自动片剂摆药机具有很高的应用价值,符合药房自动化的趋势,但在使用过程中会出现药品差错,针对不同种类的错误,需采取相应的改善措施,能有效减少差错的发生。

OBJECTIVE To propose improvement measures to reduce the error rate of unit dose dispensing by conducting a retrospective analysis of dispensing errors of automatic tablet dispensing machine in inpatient pharmacy of hospital.METHODS The error data from August to December 2020 were counted,the causes of errors were analyzed,and corresponding solutions were summarized.RESULTS The total number of errors was 134 cases,including the following four types:defects and fragments of medication(84 cases),wrong quantity of medication(34 cases),mixed packages of medication(14 cases)and human errors(2 cases).CONCLUSION The application of automatic tablet dispensing machine is of great value and conform to the trend of pharmacy automation.However,errors may occur during the application.For different types of errors,corresponding improvement measures are needed to reduce the incidence of medication errors.