医疗失效模式与效应分析在儿科静脉用药调配中的应用  

Medical Failure Mode and Effect Analysis in Pediatric Intravenous Drug Admixture

作　　者：李红云[1] 汪惠 边书芹 芦霜 张继芝[3] LI Hong-yun;WANG Hui;BIAN Shu-qin;LU Shuang;ZHANG Ji-zhi

机构地区：[1]聊城市第二人民医院山东第一医科大学附属聊城二院静脉用药调配室,山东临清252600 [2]聊城市第二人民医院山东第一医科大学附属聊城二院脊柱外科,山东临清252600 [3]聊城市第二人民医院山东第一医科大学附属聊城二院护理部,山东临清252600

出　　处：《护理学报》2020年第20期12-16,共5页Journal of Nursing（China）

基　　金：聊城市科技公关项目[聊卫医函(2017)9号-2017149]。

摘　　要：目的探讨医疗失效模式与效应分析在儿科静脉用药调配中的应用效果。方法成立医疗失效模式与效应分析小组并绘制儿科静脉药物调配流程图,以风险危机值评估流程中潜在的失效模式,对风险危机值≥8分的项目制定整改措施并实施,比较实施前后儿科静脉用药调配的差错率及失效模式的风险危机值。结果医疗失效模式与效应分析实施后儿科静脉用药调配差错率由0.120%降为0.026%,差异有统计学意义(P<0.05);实施后药物与标签不符、调配剂量不准确、溶媒量与标签不符、肠外营养液调配顺序错误、注射器漏液(微量泵专用)、液体内有异物及签字或标识不完整7项失效模式的风险危机值均比实施前下降,差异有统计学意义(P<0.05);结论对儿科静脉用药调配工作流程运用医疗失效模式与效应分析,可降低儿科静脉用药调配差错率,值得临床借鉴使用。Objective To explore the application effect of medical failure mode and effect analysis(FMEA)in pediatric intravenous drug admixture.Methods We established a FMEA team and drew a flow chart of pediatric intravenous drug admixture.Then we took measures for the improvement of projects with risk priority numbers≥8.The error rate of pediatric intravenous admixture and risk priority numbers of the failure modes before and after the implementation of FMEA was compared.Results The error rate of pediatric intravenous drug admixture was reduced from 0.120%to 0.026%and the difference was statistically significant(P<0.05).The risk priority numbers of the seven failure modes,such as mismatch between drug and the label,inaccurate doses,inconsistent amounts of solvents and labels,wrong sequence of parenteral nutrient solution admixture,leakage of syringes for micro-pump,foreign matter in the liquid and incomplete signature were significantly lower than before,showing statistical significance(P<0.05).Conclusion FEMA in pediatric intravenous drug admixture is effective for reducing the error rate,which is worthy to be promoted in clinical practice.

关 键 词：儿科 静脉用药调配中心 医疗失效模式与效应分析 差错率 

分 类 号：R472[医药卫生—护理学]