失效模式与效应分析在预防医院用药差错/用药接近差错中的应用

Application of Failure Mode and Effect Analysis in Prevention of Medication Errors/Medication Proximity Errors in the Hospital

目的:探讨失效模式与效应分析(FMEA)在预防昆明市第一人民医院用药差错/用药接近差错中的应用效果。方法:应用FMEA对该院用药流程中潜在的风险环节进行评估分析,结合医院实际情况制定相应的整改措施,比较实施前后用药流程管理风险值(RPN)、用药差错/用药接近差错率以及医嘱合格率。结果:FMEA实施后RPN显著低于实施前RPN(P<0.01),用药差错/用药接近差错率从3.23‰降低至0.26‰(P<0.05),医嘱合格率从99.60%升高至99.83%。结论:应用FMEA能前瞻性地发现用药流程中潜在的风险,从而对全院用药流程进行优化,减少用药差错/用药接近差错的发生,保障患者用药安全。

Objective:To investigate the application effect of failure mode and effect analysis(FMEA)in preventing medication errors/medication proximity errors in the First People’s Hospital of Kunming.Methods:FMEA was used to evaluate and analyze the potential risk links in the medication process management of this hospital,and corresponding corrective measures were formulated according to the actual situation of the hospital.The risk priority number(RPN)of medication process management,medication errors/medication proximity errors rate and the doctor’s order acceptance rate were compared before and after the implementation.Results:The RPN value after the implementation of FMEA was significantly lower than that before implementation(P<0.01),the rate of medication errors/medication proximity errors decreased from 3.23‰to 0.26‰(P<0.05),the doctor’s order acceptance rate increased from 99.60%to 99.83%.Conclusion:The application of FMEA can proactively identify potential risk in the management and safety of medication process,so as to optimize the medication process of the whole hospital,reduce the occurrence of medication errors/medication proximity errors,and ensure the medication safety of patients.