基于失效模式和效应分析优化静脉用药调配中心鞘注液调配流程  

Optimization of Dispensing Process for Intrathecal Injection in Pharmacy Intravenous Admixture Services Based on Failure Mode and Effects Analysis

作　　者：陶柏成[1] 王梅 刘杨 张先明[1] 周丽芳[1] 袁树伟 Tao Baicheng;Wang Mei;Liu Yang;Zhang Xianming;Zhou Lifang;Yuan Shuwei(Children’s Hospital Affiliated to Soochow University,Jiangsu Suzhou 215025,China)

机构地区：[1]苏州大学附属儿童医院,江苏苏州215025

出　　处：《儿科药学杂志》2025年第2期26-31,共6页Journal of Pediatric Pharmacy

基　　金：江苏省药学会-正大天晴医院药学科研基金项目,编号Q202234。

摘　　要：目的:分析静脉用药调配中心(PIVAS)鞘注液调配流程中的质量控制体系,优化鞘注液调配流程,提高患者用药安全性。方法:应用失效模式和效应分析(FMEA)对PIVAS鞘注液调配流程中的风险点进行评估,选出中、高风险等级的失效模式,对失效原因进行分析,制定相应的改进措施,并对质量控制效果进行评价。结果:在PIVAS鞘注液调配流程中,共找出34项中、高风险点,从人员培训、流程改进以及质量控制检查监督等方面进行改进。34项中、高风险点经过6个月的改进后,风险优先指数(RPN)下降了57.9%,药师手卫生依从性提高,鞘注液的调配契合率从改善前的96.3%增至改善后的97.7%,催询医嘱数由(13.7±2.3)条/月下降至(8.2±1.3)条/月,降幅40.1%。结论:FMEA可以对PIVAS鞘注液调配流程中的质量控制风险点进行识别与评估,建立鞘注液调配流程质量控制体系,可及时发现流程中的中高风险点,提高患者用药的安全性。Objective:To analyze the quality control system in the dispensing process of Pharmacy Intravenous Admixture Services(PIVAS),optimize the dispensing process of intrathecal injection and improve the medication safety of patients.Methods:Failure mode and effects analysis(FMEA)was used to evaluate the risk points in the dispensing process of PIVAS and select the failure modes of medium and high risk levels.The causes of failure were analyzed to develop corresponding improvement measures,and the effectiveness of quality control was evaluated.Results:A total of 34 medium and high risk points were identified in the dispensing process for intrathecal injection in PIVAS,and improvements were made in personnel training,process improvement,quality control and inspection supervision.After 6 months of improvement for 34 medium and high risk points,the average risk priority number(RPN)decreased by 57.9%,the compliance rate of hand hygiene in pharmacists were improved,the compatibility rate of intrathecal injection increased from 96.3% before improvement to 97.7% after improvement,and the number of outdated medical orders decreased from(13.7±2.3)pieces per month to(8.2±1.3)pieces per month,with a decrease of 40.1%.Conclusion:The quality control risk points of intrathecal injection in the dispensing process of PIVAS can be identified and evaluated by FMEA.The quality control system in the dispensing process for intrathecal injection can timely identify medium and high risk points in the process,improve the medication safety in patients.

关 键 词：失效模式和效应分析 静脉用药调配中心 鞘注液 质量控制体系 

分 类 号：R95[医药卫生—药学]