医疗失效模式与效应分析在身份识别用药错误预防中的应用探讨

Application of HFMEA in the prevention of medication errors in patient identification

目的通过基于个人数字助理(PDA)构建信息安全屏障以规范护士静脉用药执行过程中的患者身份识别和用药流程,确保住院患者用药安全,防范身份识别用药错误的发生。方法2019年9月运用医疗失效模式与效应分析(HFMEA)质量管理方法,对住院患者静脉用药的PDA执行流程进行分析,针对护士静脉用药操作过程中的风险环节和因素通过优化操作流程和改进信息系统程序设定等措施进行风险管控,使身份识别用药错误得到有效控制。结果用药过程实现了全院、全员、全流程、全覆盖的无缝管理,护士PDA使用依从性大幅提升,患者身份识别用药错误零发生。结论运用HFMEA质量管理方法前瞻性的对住院患者静脉用药PDA执行流程进行系统梳理,对风险环节进行流程再造,建立了基于PDA的信息安全屏障,并形成闭环管理,有效保障了患者的用药安全。

Objective Based on personal digital assistant(PDA)information security barrier,the identification of patients in the process of medication is standardized to ensure the medication safety of hospitalized patients and prevent the occurrence of medication errors.Methods By using the quality management method of healthcare failure mode and effect analysis,this paper analyzed the PDA execution process of inpatients'intravenous medication.Aiming at the risk links and factors in the operation process of nurses'intravenous medication,it carried out risk management and control by optimizing the operation process and improving the information system program setting,so as to effectively control the patient identification medication errors.Results The medication process achieved seamless management of the whole hospital,the whole staff,the whole process,and the whole coverage.The nurses'compliance of PDA use was greatly improved,and there was no medication error in patient identification.Conclusion The paper used the method of quality management of healthcare failure mode and effect analysis to systematically sort out the implementation process of in-patient intravenous drug,reengineering the risk process,establishing the information security barrier based on PDA,and forming a closed-loop management,effectively ensuring the safety of patients.