基于互动式病人参与理论的社区慢性病病人药物不良事件根因分析  

Root cause analysis of adverse drug events of chronic disease patients in community based on theoretical of patient participation in patient safety

作　　者：周婷婷[1] 谢莉玲[1] 赵庆华[1] 蒋登碧 李昱 何芳[1] ZHOU Tingting;XIE Liling;ZHAO Qinghua;JIANG Dengbi;LI Yu;HE Fang(The First Affiliated Hospital of Chongqing Medical University,Chongqing 400016 China)

机构地区：[1]重庆医科大学附属第一医院,重庆400016 [2]大溪沟社区卫生服务中心 [3]上清寺社区卫生服务中心

出　　处：《护理研究》2022年第18期3252-3257,共6页Chinese Nursing Research

基　　金：重庆市科卫联合医学科研项目,编号:2020MSXM077;中华医学会护理发展课题,编号:CMAPH-NRD2021004。

摘　　要：目的:基于互动式病人参与病人安全理论分析社区慢性病病人药物不良事件的根本原因。方法:采用便利抽样法选取2018年1月1日—2021年8月31日重庆市主城区8所社区卫生服务中心的114例慢性病病人为研究对象,运用安全风险评估矩阵筛选不良事件,基于互动式病人参与病人安全理论绘制鱼骨图分析主要原因,采用“5WHY”法分析根本原因。结果:信息不匹配、信任不足、沟通障碍和支持不力是导致药物不良事件的根本原因。结论:从病人视角分析药物不良事件具有重要意义,鼓励病人上报和自我报告不良事件、提升服药依从性以减少药物不良事件发生风险。Objective:To analyze root causes of adverse drug events of chronic disease patients in community based on theoretical of patient participation in patient safety.Methods:114 chronic disease patients in eight community health service centers in main urban area of Chongqing were selected as study subjects from January 1,2018 to August 31,2021.Adverse events were screened by Safety Assessment Code.Major cause was analysed by fish bone diagram based on theoretical of patient participation in patient safety.Root cause was analysed by"5 WHY"method.Results:Information mismatch,lack of trust,communication barriers and poor support were root causes of adverse drug events.Conclusions:It has great significance to analyze adverse drug events from perspective of patients,encouraging patients to report and self-report adverse events,and improving medication compliance to reduce risk of adverse drug events.

关 键 词：病人参与病人安全 药物不良事件 安全用药 根因分析 护理 

分 类 号：R473.2[医药卫生—护理学]