基于根本原因分析法的给药差错整改1例报道

Rectification effect of medication errors based on root cause analysis:a case report

药物安全不良事件是医疗卫生系统中最常见和普遍的患者安全问题之一,严重影响患者的生命健康和医院的声誉。本文借鉴1例给药差错案例,按照根本原因分析法(root cause analysis method,RCA)的要求,使用问题树寻找近端原因、5 Why工具法确认根本原因,并针对其采取多部门联动的系统改进措施,完善药物安全管理系统。改进后,药师调剂规范率和护士药品配置二人核对率提高,药房潜在给药差错事件减少。对安全事件进行根本原因分析,易于制定有效、系统的改进措施,使解决方案切实有效。

Medication errors are one of the most common and pervasive patient safety issues in the healthcare system,severely impacting patient health and a hospital’s reputation.This paper reports a case of real medication errors.According to the requirements of root cause analysis method(RCA),the problem tree was used to find the proximal cause the root cause was confirmed with 5 Why tool method.Multidepartmental linkage system improvement measures were taken to improve the drug safety management system.After the implementation,the standardization rates of pharmacists’prescription and nurse’s double checkups increased and the number of potential medication-related errors in pharmacy were reduced.Perform RCA on medication errors helps to draw up effective and systematic improvement measures,so that to make the solutions effective.