基于失效模式与效应分析联合根本原因分析法探索给药错误发生原因  

Causes of medication errors based on failure mode and effect analysis combined with root cause analysis

作　　者：陈娟慧[1] 陶艳玲[1] 李丽娟[1] 黄淑芳 张福珍[1] 王丹丹[3] 童杰[4] 邱萍 CHEN Juanhui;TAO Yanling;LI Lijuan;HUANG Shufang;ZHANG Fuzhen;WANG Dandan;TONG Jie;QIU Ping(Department of Nursing,Longgang District Central Hospital of Shenzhen,Guangdong Province,Shenzhen,518116,China;Community Health Management Center,Shenzhen Longgang Second People's Hospital,Guangdong Province,Shenzhen,518112,China;Thyroid and Breast Surgery,Longgang District Central Hospital of Shenzhen,Guangdong Province,Shenzhen,518116,China;Network Center,Longgang District Central Hospital of Shenzhen,Guangdong Province,Shenzhen,518116,China)

机构地区：[1]深圳市龙岗中心医院护理部,广东深圳518116 [2]深圳市龙岗区第二人民医院社康中心,广东深圳518112 [3]深圳市龙岗中心医院甲乳外科,广东深圳518116 [4]深圳市龙岗中心医院网络中心,广东深圳518116

出　　处：《中国当代医药》2023年第24期161-167,共7页China Modern Medicine

基　　金：广东省深圳市龙岗区医疗卫生科技计划项目(LG KCYLWS2020128)。

摘　　要：目的基于失效模式与效应分析联合根本原因分析法探索给药错误发生原因,为制订降低护士给药错误发生率对策提供参考依据。方法收集深圳市龙岗中心医院2019年1月至2021年12月上报的63例给药错误不良事件报表,整理与分析汇总,依次通过根本原因法中的头脑风暴法、鱼骨图、特性要因评价、真因查验等确定真因,统计各真因的风险优先系数确定主要失效模式,分析给药错误危险因素及不良事件各项特征的分布差异。结果给药错误主要失效模式是给药核查、身份核查和打印执行单或转抄三大环节,给药核查主要的危险因素是未核查药名(注射剂)、无单给药(口服药)和药名相似;身份核查主要的危险因素是被打扰;打印执行单或转抄主要的危险因素是漏打印。不同事件级别风险优先指数比较,差异有统计学意义(P<0.05);不同科系、事件类型、当事人身份、当事人职称、当事人学历、当事人工龄、发生时段与班次、药物类型、注射剂、事件发生阶段、危险因素风险优先指数比较,差异无统计学意义(P>0.05)。不同事件类型、药物类型和发生阶段的给药错误危险因素、给药错误事件级别的发生阶段和当事人学历分布和给药错误注射剂的科系分布,差异有统计学差异(P<0.05)。结论基于失效模式与效应分析联合根本原因分析法能找到给药错误的主要危险因素及不良事件的特征分布,临床管理者应结合给药错误主要危险因素及其特点采用针对性预防措施,降低给药错误发生率。Objective To explore the causes of medication errors based on failure mode and effect analysis combined with root cause analysis,so as to provide a reference for formulating strategies to reduce the incidence of nurses'medication errors.Methods A total of 63 cases of adverse event reports of medication errors reported in Longgang District Central Hospital of Shenzhen from January 2019 to December 2021 were collected,sorted out,analyzed and summarized.The real causes were determined by brainstorming method,fishbone diagram,characteristic principal cause evaluation,and real cause inspection in turn,and the main failure modes were determined by calculating the risk priority coefficient of each cause.The differences in the distribution of risk factors for medication errors and characteristics of adverse events were analyzed.Results The main failure modes of medication errors were medication verification,identity verification,and printing execution sheet or translation.The main risk factors of medication verification were drug name not checked(injection),drug without medication sheet(oral medication),and similar drug names.The main risk factor of identity verification was being disturbed,and the main risk factor for printing execution order or copy is missed printing.There was a statistically significant difference in risk priority index between different event levels(P<0.05).There were no significant differences in different departments,incident type,party identity,party title,party education,party length of service,occurrence time and shift,drug type,injection,event stage,and risk priority index of risk factors(P>0.05).There were statistically significant differences in the risk factors of medication error in different event types,drug types and occurrence stages,the occurrence stages of medication error events,the distribution of the parties'education background and the distribution of the departments of the wrong injection(P<0.05).Conclusion Based on failure mode and effect analysis combined with root cause analys

关 键 词：给药错误 失效模式与效应分析 风险优先系数 根本原因分析法 

分 类 号：R954[医药卫生—药学]