静脉药物配置护士差错分析与控制措施  

Analysis of the nurses’ errors in PIVAS and countermeasures

作　　者：张向群[1] 陈罕[1] 刘勇慧[1] 梁瑜[1] 梁瑞花[1] 

机构地区：[1]肇庆市第一人民医院,526021

出　　处：《国际医药卫生导报》2010年第1期105-107,共3页International Medicine and Health Guidance News

摘　　要：目的为保障静脉药物配置安全,减少和避免药疗差错提供参考。方法根据药品说明书、《中国药典》、《临床用药须知》等相关规定,对2006年8月至2009年8月我院静脉药物配置中心配置护士差错进行分析,并针对性地制定了控制措施。结果静脉药物配置护士内错率为0.005%;差错率为0.0036%。主要发生在未实行两步稀释法、漏做标记、混淆药品规格、药物剂量不准确、全营养混合液顺序有误等工作环节。结论配置护士必须加强药学知识和药品说明书的学习,加强职业道德教育,提高责任心,及时修正其不良行为,才能将差错发生率降至最低,保证药物安全性和有效性。Objective To ensure the safety of pharmacy of the intravenous admixture and to make a reference for the reduction and avoidance of the medication errors.Methods The errors which were made by the nurses of PIVAS during the time from August 2006 to August 2009 were analyzed in accordance with drug package inserts, Chinese Pharmacopeia, and Clinical Medication Information, meanwhile the countermeasures were formulated.Results The internal ratio of errors in the pharmacy of intravenous admixture service was 0.005% and the ratio of errors was 0.0036%.The errors occurred mainly in the following steps：unpracticed two-step dilution, the missing marks, confusion of drug specifications, missing medicine as well as the wrong orders of TNA.Conclusions The nurses of PIVAS must strengthen the study in pharmaceutical knowledge and drug package inserts, strengthen education in professional ethics, improve the responsibility, correct had behavior in order to make the ratio of errors lowest and ensure the drug safe and effective.

关 键 词：静脉药物配置 差错分析 安全用药 

分 类 号：R472[医药卫生—护理学]