某院静脉用抗肿瘤药物给药全程质量控制的实践探索

Whole-process quality control for intravenous antitumor drug administration in a hospital

目的为静脉用抗肿瘤药物的安全、合理使用提供参考。方法通过总结某院静脉用抗肿瘤药物使用中存在的问题,制定相应的改进措施,包括成立质量管理小组、更新制度与优化流程、完善信息系统、加强人员培训,并从给药前、给药中、给药后对静脉用抗肿瘤药物实施全面质量控制,比较实施前后的质控效果。结果实施给药全程质量控制后,达到2个方面的效果。一是提高了患者的用药安全。一方面确保了医嘱的合理性及输液批次的正确划分;另一方面大大提高了给药环节的正确操作率。实施给药全程质量控制8个月后,静脉用抗肿瘤药物专用输液器使用、滴注时间、顺序依赖性抗肿瘤药物输注间隔时间这3个方面的合格率分别由实施前即2020年11月至2021年6月的49.5%、64.3%、39.0%上升至实施后即2021年7月至2022年2月的97.5%、75.5%、70.6%,P<0.01。二是通过成品输液标签标注及微信公众号的科普知识宣传提高了临床护士的满意度。结论给药全程质量控制模式可促进静脉用抗肿瘤药物的安全、合理使用。

Objective To provide reference for the safe and rational use of intravenous antitumor drugs.Methods Based on the problems related to the use of intravenous antitumor drugs in our hospital,we developed and implemented solutions including establishing a quality management team,updating the systems and processes,improving the information system,and strengthening staff training.Comprehensive quality control of intravenous antitumor drugs was performed before,during,and after drug administration,and the quality control performance was compared before and after implementation.Results Two aspects of achievements were made after the implementation of the whole-process quality control for intravenous antitumor drug administration.First,it improved the medication safety by ensuring the rationality of medical prescriptions,the correct division of infusion batches,and second,the correct operation during drug administration.After 8 months of implementation,the qualification rates of the use of special infusion sets for intravenous antitumor drugs,the drip time,and the intervals among infusions of sequence-dependent antitumor drugs increased from 49.5%,64.3%,and 39.0%before implementation(during the period from November 2020 to June 2021)to 97.5%,75.5%,and 70.6%after implementation(during the period from July 2021 to February 2022)(all P<0.01).Second,labeling after preparation of intravenous infusion drugs and health education via the WeChat public account increased the satisfaction of clinical nurses.Conclusions The full-process quality control mode can promote the safe and rational use of intravenous antitumor drugs.