彩色标签对麻醉危机事件处理中用药差错与时间的影响  

The effects of color-coded drug label on medication errors and administration time in the management of anesthesia crisis events

作　　者：汤奕洁 陈梦楠 龚灿生[2] 戴东升 苏永俊 吴海星 邱良诚[1] 吴晓丹[1] TANG Yijie;CHEN Mengnan;GONG Cansheng;DAI Dongsheng;SU Yongjun;WU Haixing;QIU Liangcheng;WU Xiaodan(Department of Anesthesiology,Fujian Provincial Hospital South Branch,Provincial Clinical Medical College of Fujian Medical University,Fuzhou 350001;Department of Anesthesiology,Fujian Provincial Hospital,Provincial Clinical Medical College of Fujian Medical University,Fuzhou 350001,China)

机构地区：[1]福建医科大学省立临床医学院,福建省立医院南院麻醉科,福建福州350001 [2]福建医科大学省立临床医学院,福建省立医院麻醉科,福建福州350001

出　　处：《麻醉安全与质控》2021年第1期18-22,共5页Perioperative Safety and Quality Assurance

基　　金：福建医科大学教育教学改革研究项目(J18026)。

摘　　要：目的评价彩色标签对麻醉危机事件处理中用药差错发生率与用药时间的影响。方法采用二阶段交叉试验设计,选择20名麻醉科一线实习医生,年龄21~24岁,随机分为A组和B组,每组10人,分别使用彩色标签或传统标签标记药物对模拟人进行麻醉危机模拟事件演练;洗脱4周后,2组交换标签进行第二阶段模拟演练。在麻醉系模拟实验中心模拟真实手术室,采集演练视频,分析用药差错率及用药时间;演练结束后,针对发生用药差错的医生进行调查问卷,以了解用药差错的促成因素。结果使用彩色标签时,有12名(60%)一线实习医生至少发生一次用药差错;使用传统标签时,有16名(80%)一线实习医生至少发生一次用药差错(P>0.05)。本研究中共发生44次(8.40%)用药差错,主要为遗漏和用药剂量错误,分别为18次(40.9%)和15次(34.1%);使用彩色标签与传统标签时的平均用药差错率分别为7.2%(95%CI 4.0%~10.3%)和9.8%(95%CI 6.2%~13.5%),差异无统计学意义(P>0.05)。用药差错促成因素分析,导致用药差错的最主要因素为匆忙(29.41%)、粗心大意(17.65%)和操作不规范(13.73%)。使用不同标签时的用药时间比较,彩色标签时的用药时间(18.4±1.3)s显著快于使用传统标签(26.3±1.6)s(P<0.05)。结论各种药品准备完善下,使用彩色标签可明显缩短麻醉危机事件处理中的用药时间,但未能降低一线医生的差错发生率。Objective To evaluate the effects of color-coded drug label on medication errors and administration time in the management of anesthesia crisis events.Methods We performed a two phase crossover study in which 20 interns,aged 21 to 24,were randomly assigned into group A(n=10)and group B(n=10).A simulated critical scenario of anesthesia was carried out in an actual operation room,using color-coded label or conventional label.After a washout period of 4 weeks,a similar scenario was completed using labels in an opposite order.Videos were recorded to capture the medication errors and the administration time.After the drills,a questionnaire survey about the contributing factors of medication errors was carried out in those who had made errors.Results With the application of color-coded labels,12 of the 20 interns(60%)made at least 1 medication error while 16(80%)of those using the conventional label(P>0.05).In total,44 medication errors occurred,in which the most common types were omission(40.9%)and incorrect dose(34.1%).No difference was found in the incidence of medication errors when using the color-coded label(7.2%;95%CI 4.0%-10.3%)or the conventional label(9.8%;95%CI 6.2%-13.5%)(P>0.05).The top contributing factors were busyness(29.41%),carelessness(17.65%)and irregular operations(13.73%).The administration time was significantly shorter when using the color-coded label[(18.4±1.3)s vs(26.3±1.6)s,(P<0.05)].Conclusion The color-coded label,although did not reduce the incidence of medication errors under the condition that all the medications had been prepared in advance,could indeed significantly shorten the administration time in the management of anesthesia crisis events.

关 键 词：彩色标签 用药差错 用药时间 危机事件 

分 类 号：R95[医药卫生—药学]