“瑞士奶酪模型”在重症监护室安全用药管理中的应用  

Application of Swiss-Cheese model in ICU safe medication management

作　　者：杨素 范颖[1] YANG Su;FAN Ying(EICU,Renji Hospital Affiliated with Shanghai Jiaotong University School of Medicine,Shanghai,201112)

机构地区：[1]上海交通大学医学院附属仁济医院急诊监护室,上海201112

出　　处：《中西医结合护理（中英文）》2018年第9期53-56,共4页Journal of Clinical Nursing in Practice

摘　　要：目的探讨"瑞士奶酪模型"在重症监护室安全用药管理中的应用效果。方法应用"瑞士奶酪模型"对科室2016年1月—12月发生的12例次药物差错进行回顾性分析,从组织影响、不安全的监督、不安全行为先兆及不安全操作行为四个方面进行根因分析并制定改进措施,于2017年1月—12月将"瑞士奶酪模型"用于监护室安全用药管理,落实整改措施。比较运用"瑞士奶酪模型"管理前后用药差错发生率、科室护士对监护室药物知识知晓率、患者满意度。结果运用"瑞士奶酪模型"进行重症监护室安全用药管理后,监护室用药差错发生率由实施前的4. 68‰下降到0. 80‰,护士对监护室药物知识知晓率由78. 18%提高到92. 72%,患者满意度由之前的80. 56%上升到97. 22%,差异有统计学意义(P <0. 05)。结论将"瑞士奶酪模型"应用于重症监护室的安全用药管理,可降低科室用药差错的发生率,提高护理人员监护室用药知识水平及患者满意度,提高重症监护室护理管理质量。Objective To explore the effect of Swiss-Cheese model in the safe medication management of ICU. Methods A retrospective analysis of 12 cases of medication errors oc- curred between January 2016 and December 2016 was conducted by using Swiss-Cheese model Root causes of these medication errors were analyzed from the perspective of organization and management , unsafe monitoring, indicators of unsafe performance and unsafe operation. From January 2017 to December, corresponding measures were carried out. The incidence of medication errors, nurses＇knowledge about drugs, patients＂ satisfaction degree were evaluated and compared before and after implementation of Swiss-Cheese model. Results After implementation of Swiss- Cheese model, the incidence of medication errors in ICU decreased from 4.68%0 to 0.80%0, the rate of nurses＇knowledge of drugs increased from 78.18% to 92.72%, the Patients＂ satisfaction degree increased from 80.56 % to 97.22 %, with significant differences （P 〈 0.05 ）. Conclusion The application of Swiss-Cheese model in the safe medication management of ICU can reduce the incidence of medication errors, improve the knowledge level of nurses and patients＂ satisfaction, and improve the quality of nursing management in ICU.

关 键 词：瑞士奶酪模型 重症监护室 安全用药 输液 

分 类 号：R473.5[医药卫生—护理学]