医院静脉用药调配中心141例差错分析  

Analysis of 141 Cases of Medication Errors in Pharmacy Intravenous Admixture Services in a Hospital

作　　者：郎宇[1] 周虹[1] 张征[1] 

机构地区：[1]首都医科大学附属北京朝阳医院,北京100020

出　　处：《中国药业》2017年第19期92-95,共4页China Pharmaceuticals

摘　　要：目的降低静脉用药调配中心(PIVAS)的差错发生率,提高静脉用药调配质量,保证临床用药安全。方法收集医院PIVAS 2016年3月至4月差错报告,按照差错发生率、差错发生环节、差错内容、差错发生时间、差错药品分类及引发和发现差错人员进行分析。结果共纳入141例差错报告,总发生率为0.13%;主要发生差错的环节是摆药、贴签和混合调配;引起差错的人员包括药师、护士和工人;差错内容主要包括溶剂错误和药品种类、规格、数量错误等;差错发生环节主要包括贴签、摆药、配制和配送等。结论通过分析差错发生原因,制订相应的防范措施,保证临床用药更加安全有效。Objective To reduce the incidence rate of errors in pharmacy intravenous admixture services （ PIVAS ） , improve the quality of intravenous drug dispensing and ensure the safety of clinical medication. Methods The error reports were collected from March to April2016 in PIVAS of Beijing Chaoyang Hospital. The error rates, occurrence step of errors, error content, and occurrence time of errors, clas-sification of error drugs, and personnel who caused and discovered errors were analyzed. Results A total of 141 errors were reported, with a total incidence of 0. 13%. The main steps of errors were drug dispensing, labeling, and configuration. People who caused errors include pharmacists, nurses and workers, the errors mainly include solvent errors and drug categories, specifications and quantity errors and so on. The main steps of errors include labeling, dispensing, preparation and distribution and so on. Conclusion The corresponding preventive measures were formulated to ensure the safety and effectiveness of clinical medication by analyzing the causes of errors.

关 键 词：静脉用药物调配中心 用药差错 药房管理 

分 类 号：R952[医药卫生—药学]