临床给药错误特性分析及安全管理对策  

Clinical medication error characteristics analysis and safety management countermeasures

作　　者：周月华[1] 王青云[2] 林丽华[3] 

机构地区：[1] 浙江省平阳县人民医院保健科, 温州325400 [2] 浙江省平阳县人民医院骨科, 温州325400 [3] 浙江省平阳县人民医院泌尿科, 温州325400

出　　处：《中华现代护理杂志》2014年第7期839-843,共5页Chinese Journal of Modern Nursing

摘　　要：目的：探讨如何避免给药错误的发生，研究相应防范管理对策，提高临床给药安全的管理质量。方法回顾本院2010-2012年护理不良事件系统上报的111起给药错误，对给药错误类型、原因、特点等进行分析。结果给药错误前3位为遗漏、患者身份识别错误、药物名称错误，分别占22．52％，20．72％，19．82％；给药错误的前3位原因为查对不认真、未遵守操作流程、沟通不良，分别占21．62％，16．22％，14．41％；年限低于5年的护士给药错误发生率占62．86％，10年以上者发生率占16．19％；1 d中给药错误发生的3个高峰时段为10：00-11：59、8：00-9：59、16：00-17：59。结论护理管理人员应根据护士给药错误的原因与特点制定针对性防范措施，加强护士责任心教育，改善工作环境，改革护理人员的排班模式，加强薄弱环节管理，加强护士培训与考核，规范科室药品管理等措施，提高给药安全。Objective To discuss how to avoid medication errors , and research relevant preventive management strategies so as to improve the quality of clinical drug safety management .Methods Analyzed the＆amp;nbsp;types, causes and features of medication errors by reviewing 111 reported nursing adverse events about the medicine mistakes between 2010 and 2012 .Results The top three sorts of medication were omittance （22.52%）, patients identification errors（20.72%） and drug name errors（19.82%）, and the top three cause were no seriously check （ 21.62%）, no complying with operation （ 16.22%） and poor communication （14.41%）.Medication error rates of nurses with less 5 work years was 62.86%,and that nurses with more than 10 work years was 16.19%.The top three medication error time slots were 10：00-11：59（25.23%）, 8：00-9：59（19.82%） and 16：00-17：59 （13.51%）.Conclusions Nursing manager should formulate the pertinence preventive measures according to the reasons and characteristics of nurse ’ s medicine errors .We can improve safety for medicine by improving staff and establishing an independent safety culture from the organization system configuration , strengthening the nurse responsibility education , improving the work condition, reforming the nursing staff scheduling model , strengthening the weak links management , strengthening the nurse training and assessment , standardizing drug management department , etc.

关 键 词：给药错误 护士 安全管理 

分 类 号：R472[医药卫生—护理学]