4 530例静脉药物配置近似错误的分布特点与对策研究

doi:10.3761/j.issn.0254-1 769.2020.09.005

摘要/Abstract

摘要：

目的分析静脉药物配置环节近似错误的发生率及分布特点,为完善管理机制,确保输液安全提供依据。方法回顾性分析2017年1月—2018年12月该院静脉药物配置中心4530例近似错误登记资料,按发生时间、药物种类、发生人群及发现人群4个维度进行分类和分析,并探讨对策。结果配置环节共发生近似错误4530例,错误发生率为1.26‰。按发生时间分类：配置前2752例（60.8%）、配置过程中1778例（39.2%）;按药物种类分类：配置过程中普通药物1756例（98.76%）、全胃肠外营养16例（0.9%）、抗肿瘤药6例（0.34%）;按发生人员分类：排药药师3183例（70.26%）、配置护士1168例（25.78%）;按发现人员分类：配置护士3133例（69.16%）、成品复核药师1 397例（30.84%）。结论静脉药物经静脉药物配置中心配置,经过多重环节核对,但近似错误仍有一定的发生率,需优化管理机制,提高安全意识,确保成品输液安全。

关键词: 静脉药物配置, 给药错误, 全胃肠外营养, 抗肿瘤药, 安全管理, 护理管理研究

Abstract:

Objective To analyze the incidence and distribution characteristics of approximate errors in intravenous drug allocation so as to provide references to improve management mechanism and ensure safe infusion.Methods A retrospective analysis was conducted in 4 530 cases of approximate errors with registration data from January 2017 to December 2018 in a Pharmacy Intravenous Admixture Service of the hospital. According to 4 dimensions including the time of occurrence,drug type,the population of occurrence and the population of discovery,this study classifies,summarizes the characteristics and discusses the countermeasures.Results There were a total of 4 530 cases of approximate errors occurring in the stage of allocation,with the error rate of 1.26‰. According to the time of occurrence,2 752 cases（60.8%） occurred before allocation and 1 778 cases （39.2%） were in the process of allocation. According to the type of drugs,1 756 cases（98.76%） of errors happened on common drugs and 16 cases（0.9%） were total parenteral nutrition,and 6 cases（0.34%） were anti-neoplastic agents during the allocation process. According to the incidence of personnel,3 183 cases（70.26%） were pharmacists;1 168 cases（25.78%） were allocation nurses. According to the population of discovery,3 133 cases（69.16%） were allocation nurses;1 397 cases（30.84%） were pharmacists.Conclusion Intravenous drug allocation has been checked through multiple procedures in Pharmacy Intravenous Admixture Service,but there is still a certain incidence of approximate errors,and it is necessary to further optimize the management mechanism,improve the awareness and skills of safe delivery,and ensure the quality of intravenous infusion.

Key words: Intravenous Drug Allocation, Medication Errors, Total Parenteral Nutrition, Antineoplastic Agents, Safety Management, Nursing Administration Research

潘慧丽,卢彬,杨燕,宋萍,徐虹,李艳,王红妹. 4 530例静脉药物配置近似错误的分布特点与对策研究[J]. 中华护理杂志, 2020, 55(9): 1310-1314.

PAN Huili,LU Bin,YANG Yan,SONG Ping,XU Hong,LI Yan,WANG Hongmei. Study on distribution characteristics and countermeasures of approximate errors in intravenous drug allocation in 4530 cases[J]. Chinese Journal of Nursing, 2020, 55(9): 1310-1314.

图/表 5

表1 2017年—2018年静脉药物配置近似错误发生率及时间分布

表2 2017年—2018年配置前近似错误具体分布[例（构成比,%）]

表3 2017年一2018年静脉药物配置过程中近似错误在不同药物中的分布

表4 2017年一 2018年普通药物配置过程中近似错误分布

表5 近似错误发现人员分布[名(百分比,%)]

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