基于失效模式和效应分析的德谷胰岛素用药错误风险点研究

Study on the risk point of medication errors of insulin degludec based on failure mode and effect analysis

目的利用失效模式和效应分析(FMEA)方法探讨德谷胰岛素(IDeg)在临床应用中存在的用药错误风险点。方法在山东第一医科大学第一附属医院建立用药错误风险点研究课题组,通过问卷调查、文献研究和实地考察等方法收集用药错误风险点,对其严重程度、发生频率和发现指数进行评分,确定风险优先级数(RPN),并制定相应的防范措施。结果通过综合评价,在医师处方、药师调剂、护士给药和患者用药4个环节共发现32个风险点。将RPN由高至低排序,筛选出10个关键风险点(RPN>70分):(1)药师未对患者进行IDeg使用指导;(2)患者不知道应主动向医师反映药品的使用感受和不良反应;(3)患者不清楚用药监测的内容;(4)患者未掌握药品的使用方法;(5)药师未对患者进行用药反馈调查;(6)患者不重视或认为没有必要接受药师的用药指导;(7)医师处方错误,导致用药过量;(8)医师与患者沟通不畅,患者不清楚自己用的是什么药;(9)药师对药品性状、禁用人群、相互作用、用药时间等药品信息了解不充分;(10)药师审核处方过程中忽略药品的常用剂量、适用人群等信息。根据上述风险点提出了针对IDeg基本信息维护、医师处方、药师调剂、患者用药、护士给药、收集用药错误报告及加强人员培训7个方面风险干预建议。结论利用FMEA法可有效找出IDeg在临床应用中存在的用药错误风险点,并可通过量化评估明确改善IDeg风险管理的优先顺序,制定相应防范措施,提高用药安全性。

Objective To explore the risks of medication errors of insulin degludec(IDeg)in clinical application using failure mode and effect analysis(FMEA).Methods A research group on the risk points of medication errors was established in the First Affiliated Hospital of Shandong First Medical University.The risk points of medication errors were collected through questionnaire survey,literature research,and on‑the‑spot investigation.The severity,frequency of occurrence,and likelihood of detection were scored to determine the risk priority number(RPN)and formulate corresponding preventive measures.Results After comprehensive evaluation,32 risk points were found in the 4 links of physician prescription,pharmacist dispensing,nurse administration,and patient medication.The RPN was ranked from high to low,and 10 key risk points(RPN>70 points)were selected.(1)The pharmacist did not give the patients guidance on the use of IDeg;(2)Patients did not know that they should actively report to the physicians about the use feeling and adverse reactions of the drug;(3)Patients did not clear about the content of medication monito-ring;(4)Patients did not master how to use the drug;(5)Pharmacists did not conduct medication feedback survey on patients;(6)Patients did not attach importance or thought it was unnecessary to receive medication guidance from pharmacists;(7)Physician′s prescription was wrong,resulting in overdose;(8)Doctors and patients did not communicate well,and patients did not know what medicine they were using;(9)Pharmacists did not fully understand drug information such as drug properties,prohibited population,interaction,medication time,etc.;(10)Pharmacists ignored the commonly used dose of the drug,applicable population,and other information in the process of reviewing the prescription.According to above‑mentioned risk points,the risk intervention suggestions of IDeg were put forward,including the maintenance of basic drug information,the prescription of doctors,the dispensing of pharmacists,the patient medication link,the nurse administration link,the collection of medication error reports,and the strengthening of personnel training.Conclusion The FMEA method can be used to effectively find out the risk points of medication errors in the clinical application of IDeg,the priority of IDeg risk management can be determined through quantitative evaluation,and corresponding preventive measures can be formulated.