一起疑似输液不良反应聚集事件的分析及干预  

Analysis and intervention of a suspected cluster event with adverse infusion reactions

作　　者：周晓红 李晓君 郭健芬[1] 段妍 袁琳[1] ZHOU Xiao-hong;LI Xiao-jun;GUO Jian-fen;DUAN Yan;YUAN Lin(Guangdong Second Hospital of Traditional Chinese Medicine,Guangzhou,Guangdong 510095,China)

机构地区：[1]广东省第二中医院,广东广州510095

出　　处：《中国卫生检验杂志》2023年第15期1909-1911,共3页Chinese Journal of Health Laboratory Technology

基　　金：广东省医学科学技术研究基金项目(B2022190)。

摘　　要：目的报告3例疑似输液不良反应患者的临床资料,探讨输液不良反应的危险因素及有效防控策略。方法采用临床资料调查和现场采样相结合的方法对一起输液不良反应疑似聚集事件进行分析,查找发生原因及传播途径,并进行干预处置。结果某病区出现输液不良反应的3例患者,前后横跨24 d,无短时间内聚集暴发;输液不良反应主要表现有寒战、高热、体温38.2℃~38.5℃。2名配药护士卫生消毒手菌落数超标监测不合格,及时采取综合干预措施后,疑似聚集输液不良反应得到有效控制,干预前后相关指标差异有统计学意义(P<0.05)。结论发生输液不良反应疑似聚集事件后,及时分析原因并采取综合干预措施,对于预防事件发展有良好的作用。应通过加强配药输液环节手卫生;推动静脉配置中心建设;多渠道加强静脉配液的质量控制等工作防范输液不良反应聚集事件发生。Objective This paper aims to report the clinical data of 3 patients with suspected adverse infusion reactions.The risk factors and effective prevention and control strategies of adverse infusion reactions were discussed.Methods Clinical data investigation and field sampling were used to analyze a suspected cluster of adverse infusion reactions,find out the causes and transmission routes,and conduct intervention.Results There were 3 patients with adverse infusion reactions in a ward,which lasted for 24 days before and after,and no outbreak occurred in a short time.The adverse reactions of infusion mainly showed chills,high fever,and body temperature of 38.2℃-38.5℃.The number of bacterial colonies on the hands of 2 dispensing nurses exceeded the standard for hygienic disinfection.After comprehensive intervention measures were taken in time,the suspected adverse reactions of aggregation infusion were effectively controlled,and the relevant indicators before and after intervention had statistical significance(P<0.05).Conclusion After the occurrence of the suspected cluster event of adverse infusion reactions,timely analysis of the causes and comprehensive intervention measures have a good effect on preventing the development of the event.Hand hygiene should be strengthened during dispensing and infusion,the construction of venous allocation center should be promoted,and the quality control of intravenous liquid dispensing should be strengthened through multiple channels to prevent the occurrence of adverse reactions.

关 键 词：输液不良反应 聚集 分析 干预 

分 类 号：R826.26[医药卫生—临床医学]