静脉用药调配中心调剂差错与防范措施分析

Dispensing Errors and Preventive Measures in Pharmacy Intravenous Admixture Services

目的分析静脉用药调配中心(PIVAS)调剂差错发生的原因,降低医院调剂差错率。方法根据层次任务分析(HTA)-人为差错模式(HET)理论分解PIVAS调剂流程,确定调剂差错类型,构建HTA-HET数据统计表;分析2020年7月至12月(整改前)的调剂差错,并制订防范措施,与2021年1月至6月(整改后)的调剂差错进行比较。结果共收集整改前的医嘱127262条,调剂差错512条;整改后的医嘱132983条,调剂差错392条。整改前,各项子流程调剂差错排名前3的分别为摆放主药、溶剂贴签、加药混合调配,占比分别为26.17%,21.48%,16.80%;主要调剂差错类型分别为品种差错、规格差错、数量差错,分别占26.76%,25.00%,18.95%。整改后,摆放主药差错率由0.105%降至0.074%,溶剂贴签差错率由0.086%降至0.053%,加药混合调配差错率由0.068%降至0.043%,成品输液核对差错率由0.020%降至0.008%,差异显著(P<0.05);品种差错率由0.108%降至0.082%,规格差错率由0.101%降至0.067%,数量差错率由0.076%降至0.043%,差异显著(P<0.05)。结论HTA-HET模型有助于分析PIVAS调剂差错的主要原因,制订有针对性的防范措施,降低调剂差错率。

Objective To analyze the causes of dispensing errors in Pharmacy Intravenous Admixture Services(PIVAS),and to reduce the dispensing error rate in the hospital.Methods The dispensing procedures of PIVAS were decomposed and the types of dispensing errors were determined by the theory of hierarchical task analysis(HTA)-human error template(HET).A statistical table of HTA-HET was constructed.The dispensing errors from July to December 2020(before the rectification)were analyzed,the preventive measures were formulated,and the above dispensing errors were compared with those from January to June 2021(after the rectification).Results A total of 127262 medical orders,512 dispensing errors before the rectification and 132983 medical orders,392 dispensing errors after the rectification were collected.Before the rectification,the top three dispensing errors in various subprocedures were main drug placing,solvent labeling and drug mixing and dispensing,accounting for 26.17%,21.48%and 16.80%,respectively.The main types of dispensing errors were variety errors,specification errors and quantity errors,accounting for 26.76%,25.00%and 18.95%,respectively.After the rectification,the error rate of main drug placing decreased from 0.105%to 0.074%,the error rate of solvent labeling decreased from 0.086%to 0.053%,the error rate of drug mixing and dispensing decreased from 0.068%to 0.043%,and the error rate of finished infusion checking decreased from 0.020%to 0.008%,with significant difference(P<0.05).After the rectification,the error rate of variety decreased from 0.108%to 0.082%,the error rate of specification decreased from 0.101%to 0.067%,and the error rate of quantity decreased from 0.076%to 0.043%,with significant difference(P<0.05).Conclusion The HTA-HET mode is helpful to analyze the main causes of dispensing errors in PIVAS and formulate the preventive measures accordingly to reduce the dispensing error rate.