静脉用药调配中心差错事故分析和防范措施探究  

Errors with Pharmacy Intravenous Admixture Services(PIVAS)and Countermeasures

作　　者：潘景光 刘敏 赵红萍 杨艳霞 马如梦[2] 赵佐庆[2] 涂艳阳[2] 张永生[2] 

机构地区：[1]解放军第五一八医院,西安710043 [2]第四军医大学唐都医院

出　　处：《解放军预防医学杂志》2017年第6期598-599,603,共3页Journal of Preventive Medicine of Chinese People's Liberation Army

基　　金：国家自然科学基金资助项目(No.81572983)

摘　　要：目的通过对静脉用药调配中心(PIVAS)工作中的差错进行分析,探究针对性的防范措施,以提高临床用药安全性。方法分析2014年8月至2015年7月本院静脉用药调配中心发生的104例差错事件,涉及的环节主要包括处方审核、摆药核对、输液调配等。结果差错事件中,审方差错、贴签差错、摆药差错、调配差错、停药嘱退药差错、成品输液发放差错的占比依次为5.77%(6/104)、21.15%(22/104)、36.54%(38/104)、15.38%(16/104)、7.70%(8/104)、13.46%(14/104)。外部人员发现的差错和内部人员发现的差错分别为80.77%(84/104)、19.23%(20/104)。结论本次研究中通过对PIVAS工作中所出现的差错予以分析,并且采取了针对性防范措施,不断改进技术、完善差错防范制度和信息系统,在一定程度上提高了临床用药的安全性,也有利于静脉用药调配中心服务水平的提高。Objective To analyze the errors with the PIVAS at our hospital and explore countermeasures to improve the safety of clinical medication. Methods From August 2014 to July 2015, 104 cases of errors occurred at the PIVAS in our hospital, involving prescription inspections, dispensing checks, and preparation and distribution of infusion solution. Results The percent- age of errors associated with prescription inspections, labeling, dispensing, preparation and distribution, drug withdrawal, and finished infusion solution was 5.77% （6/104）, 21. 15% （22/104）,36.54% （38/104）, 15.39% （16/104）, 7.69% （8/104）, and 13.46% （14/104）respectively. The errors found by outsiders and the staff made up 80.77% （84/104） and 19.23% （20/104）respectively. Conclusion An analysis of errors that occur at PIVAS can help improve the system of information and error prevention so that the safety of clinical medication can be enhanced and the quality of services at PIVAS improved.

关 键 词：静脉用药调配中心 差错事故 防范措施 

分 类 号：R96[医药卫生—药理学]