| 余资,罗宇,董卫华,等.住院药房口服单剂量调配的差错案例分析与措施改进[J].安徽医药,2019,23(6):1254-1257. |
| 住院药房口服单剂量调配的差错案例分析与措施改进 |
| Analysis and interventions of the typical cases in unit-dose dispensing errors in inpatient pharmacy |
| 投稿时间：2017-06-07 |
| DOI： |
| 中文关键词: 单剂量调配 全自动摆药机 差错案例分析 防范措施 |
| 英文关键词: Unit-dose dispensing Automatic-tablet-packing machine Analysis of error cases Precautionary measures |
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| 中文摘要: |
| 目的 降低该院口服单剂量调配差错,为提升医院住院药房口服单剂量调配工作质量提供借鉴。方法 统计西安交通大学第一附属医院2016年3—6月口服单剂量调配差错数据,应用差错类型分析法对各类型差错的典型案例进行分析,找出问题的关键并制定相应的防范措施,措施实施3个月后,统计分析2016年9—12月的差错数据以观察实施效果。结果 制定的防范措施主要包括优化工作流程、加强业务培训及复核确认、系统软件优化等；措施实施后差错发生率由0.231‰下降为0.062‰,其中人为因素导致的差错由152例下降为33例；机器自身因素导致的差错由105例下降为38例。结论 所采取的措施可有效降低口服单剂量调配的差错发生率,提高了工作质量,保证了病人口服用药的安全。 |
| 英文摘要: |
| Objective To reduce the oral single-dose deployment errors in hospitals,and to provide reference for improving the quality of oral single-dose deployment in hospital pharmacies.Methods The single-dose allocation error data of the First Affiliated Hospital of Xi'an Jiaotong University from March to June 2016 were statistically analyzed.The typical case of various types of errors was analyzed using the error type method to identify the key problems and formulate corresponding preventive measures.After 3 months of implementation of measures,the error data from September to December 2016 were statistically analyzed to observe the effect of implementation.Results The improvement measures had been formulated,including the optimization of workflow,strengthening the business training and re-checking,and system software optimization.The incidence of errors decreased from 0.231‰ to 0.062‰,of which human errors decreased from 152 to 33;machine errors decreased from 105 to 38.Conclusion The measures can effectively reduce the errors in unit dose dispensing,improve the quality of work and ensure the medication safety of oral drugs. |
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