心脏外科术中给药错误的分析及对策  

Analysis and Countermeasures of Intraoperative Drug Administration Errors in Cardiac Surgery

作　　者：梅娜[2] 李俊杰 张琳娟[1] 韦延强[1] 吴越[1] MEI Na;LI Junjie;ZHANG linjuan(The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an,Shaanxi,710061, China)

机构地区：[1]西安交通大学第一附属医院,陕西西安710061 [2]西安交通大学第一附属医院麻醉手术部,陕西西安710061

出　　处：《中国卫生质量管理》2020年第1期82-85,共4页Chinese Health Quality Management

基　　金：陕西省软科学研究计划基金项目(2018KRM109)。

摘　　要：应用根本原因分析法分析了两例心脏外科手术术中给药错误事件的原因。针对存在的共性根本原因,采取制定心脏专科带教细则及考核标准,制定心外洗手护士与巡回护士细则,制作器械台上灭菌醒目标识,制定心外术中规范化给药流程等措施。执行后,未发生同类事件。被带教护士专科技能、医护给药流程知晓率、带教老师在岗率、相关配合人员满意度均有所提升。应用根本原因分析法分析案例,可以从根源解决系统问题,保障患者安全。The root cause analysis method was used to analyze the causes of two cases of drug administration errors in cardiac surgery.In view of the common root causes,measures were taken such as formulating clinical teaching rules and assessment standards,formulating rules for hand-washing nurses and itinerant nurses in cardiac surgery,making sterilizing eye-catching signs on the instrument table,and formulating standardized drug delivery procedures in cardiac surgery.No such event occurred after implement of the measures.The professional skills of the nurses taught,the awareness rate of doctors and nurses drug administration process,the on-duty rate of the teachers taught,and the satisfaction degree of the related cooperative staff all improved.The application of root cause analysis method to analyze cases can solve the system problems from the root and ensure the safety of patients.

关 键 词：心外手术 术中给药 不良事件 根因分析法 患者安全 

分 类 号：R197.323[医药卫生—卫生事业管理]