1例用药错误事件的分析与改进  

Analysis and Improvement of A Case of Medication Error Event

作　　者：顾英[1] 房夏玲[1] 陈宁[1] 赵小燕 贺丽霞[1] 郑雪梅[1] GU Ying;FANG Xialing;CHEN Ning(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

出　　处：《中国卫生质量管理》2022年第1期69-73,共5页Chinese Health Quality Management

摘　　要：采用根本原因分析及行动法对1例儿科用药错误事件进行分析,确定根本原因,从人员、环境、制度等方面提出针对性改进措施。采取措施后,类似不良事件未再发生。建议医疗机构加强关键环节的有效沟通,鼓励患者参与医疗安全管理,营造病区安静环境,严格执行查对制度,正确识别患者身份,优化护理人力资源配置,以保证患者用药安全。Root cause analysis action was used to analyze a case of pediatric medication administration error,determine the root cause,and highlight targeted improvement measures from the aspects of personnel,environment,system,etc.After taking measures,similar adverse events did not occur again.It is suggested that medical institutions strengthen effective communication in key links,encourage patients to participate in medical safety,create a quiet ward environment,strictly implement the check system,correctly identify patient's identity,optimize the allocation of nursing human resources,and ensure the safety of patient medication.

关 键 词：患者安全 RCA2 用药错误 不良事件 

分 类 号：R197.323[医药卫生—卫生事业管理]