苯巴比妥和苯妥英钠血药浓度监测电子申请单录入错误原因分析与改进  

Analysis and Improvement of Input Errors in Electronic Application Form of Blood Concentration Monitoring of Phenobarbital and Phenytoin Sodium

作　　者：张青霞[1] 褚燕琦[1] 曾艳[1] 沈江华[1] 王欣[1] 王育琴[1] 闫素英[1] ZHANG Qingxia;CHU Yanqi;ZENG Yan;SHEN Jianghua;WANG Xin;WANG Yuqin;YAN Suying(Dept. of Pharmacy, Xuanwu Hospital of Capital Medical University/Beijing Medical Research Center for Geriatrics/National Clinical Research Center for Geriatric Disease, Beijing 100053, China)

机构地区：[1]首都医科大学宣武医院药学部/北京市老年病医疗研究中心/国家老年疾病临床医学研究中心,北京100053

出　　处：《中国医院用药评价与分析》2020年第5期617-619,624,共4页Evaluation and Analysis of Drug-use in Hospitals of China

基　　金：首都特色专项(No.Z141107002514062);北京市卫生和计划生育委员会“老年重大疾病关键技术研究”(No.PXM2017_026283_000002)。

摘　　要：目的:探讨医师开具的苯巴比妥和苯妥英钠血药浓度电子申请单录入错误的原因,并制定针对性的改进措施。方法:利用根本原因分析法,回顾性分析医师开具的苯巴比妥和苯妥英钠血药浓度电子申请单录入错误的根本原因,找出苯巴比妥和苯妥英钠药名看似听似(look-alike and sound-alike,LASA)、电脑位置相邻及医师工作繁忙核对不足两大真因,分别制定针对性的防范措施,即将计算机系统中苯巴比妥、苯妥英钠的位置隔开和针对医师核对不足进行培训,并引入PDCA循环进行逐步改进。结果:经过2轮针对性的PDCA逐步改进,医师开具的苯巴比妥、苯妥英钠血药浓度电子申请单录入错误从每月平均4例逐渐降至每月0例。结论:医师要警惕电脑系统LASA药品位置相邻带来的药品混淆错误隐患,LASA药品名称在计算机屏幕内位置隔开可以显著减少医师血药浓度申请单录入错误。OBJECTIVE:To probe into the reasons of input errors in electronic application form of blood concentration monitoring of phenobarbital and phenytoin sodium,so as to formulate specific improvement measures.METHODS:Root cause analysis was adopted to retrospectively analyze the root cause of input errors in electronic application form in blood concentration monitoring of phenobarbital and phenytoin sodium,two main reasons were found out:the Chinese names of phenobarbital and phenytoin sodium were look alike and sound-alike(LASA)and in adjacent locations in computer,the clinician was too busy to check the electronic application form.Specific preventive measures were formulated respectively:separate the locations of phenobarbital and phenytoin sodium in computer system and training the clinicians for medical order check,the PDCA cycle was also introduced to improve step by step.RESULTS:After two rounds of specific PDCA improvement,the input errors in electronic application form of blood concentration monitoring of phenobarbital and phenytoin sodium had decreased from averagely 4 cases each month to 0.CONCLUSIONS:Clinicians should be aware of possible mix-ups errors of LASA drugs and adjacent locations in computer systems,to separate the locations of LASA drugs can significantly decrease the input errors in electronic application form of blood concentration monitoring.

关 键 词：PDCA循环 血药浓度 苯巴比妥 苯妥英钠 监测错误 LASA 

分 类 号：R95[医药卫生—药学]