某院中药饮片调剂中的差错事件调查及改进措施分析  

Analysis of Dispensing Error Events and Improvement Measures of Chinese Herbal Pieces in A Hospital

作　　者：李芬 李亮 彭志婷 于丹[2] LI Fen;LI Liang;PENG Zhiting;YU Dan(Xuzhou Hospital of Traditional Chinese Medicine,Xuzhou Jiangsu 221006,China;Xuzhou Central Hospital,Xuzhou Jiangsu 221006,China)

机构地区：[1]徐州市中医院,江苏徐州221006 [2]徐州市中心医院,江苏徐州221006

出　　处：《药品评价》2024年第10期1293-1296,共4页Drug Evaluation

摘　　要：目的分析某院中药饮片调剂中的差错事件的原因和特点,提出有效的改进措施,提高中药饮片调剂的质量和安全性。方法采用回顾性调查的方法,收集2021—2023年某院中药饮片调剂中的差错事件的相关资料,包括差错类型、发生环节、责任人、影响程度等,对差错事件进行统计分析,并结合文献资料和专家意见,提出改进措施。结果共收集到某院中药饮片调剂中的差错事件72例,其中38例为处方差错,24例为调剂差错,10例为发药差错。差错事件的发生率为0.32%,其中12例造成了患者的不良反应或损害,占差错事件的16.67%。差错事件的主要原因是人为因素,包括操作失误、知识缺乏、沟通不畅、监督不足等,占差错事件的86.11%。差错事件的主要特点是多发生在高峰期、多涉及常用药、多发生在初级人员、多属于可预防性差错。改进措施包括加强人员培训、规范操作流程、完善信息系统、加强质量管理、建立差错报告和分析机制等。结论某院中药饮片调剂中的差错事件虽然发生率较低,但仍存在一定的风险和危害,需要引起高度重视。通过分析差错事件的原因和特点,可以制定针对性的改进措施,有效地预防和减少差错事件的发生,保障患者的用药安全和治疗效果。Objective To analyze the causes and characteristics of dispensing errors of Chinese herbal pieces in a hospital,and to propose effective improvement measures to enhance the quality and safety of dispensing Chinese herbal pieces.Methods A retrospective survey method was used to collect relevant data on dispensing errors of Chinese herbal pieces in a hospital from 2021 to 2023.The data included error types,occurrence link,responsible person,impact degree,etc.The dispensing errors were statistically analyzed,and improvement measures were proposed based on literature data and expert opinions.Results A total of 72 dispensing errors of Chinese herbal pieces were collected in the hospital.Among these,38 were prescription errors,24 were dispensing errors,and 10 were other types of errors.The incidence rate of dispensing errors was 0.32%.Of these errors,12 caused adverse reactions or harm to patients,accounting for 16.67%of the dispensing errors.The main causes of dispensing errors were human factors,including operational errors,lack of knowledge,poor communication,and insufficient supervision,which accounted for 86.11%of the dispensing errors.The main characteristics of dispensing errors were that they occurred more frequently during peak periods,involved commonly used drugs,occurred more frequently among primary personnel,and were preventable.Improvement measures include strengthening personnel training,standardizing operation procedures,improving information systems,enhancing quality management,and establishing error reporting and analysis mechanisms.Conclusion The incidence rate of dispensing errors of Chinese herbal pieces in the hospital is low;however,there are still risks and hazards that require significant attention.By analyzing the causes and characteristics of dispensing errors,targeted improvement measures can be formulated to effectively prevent and reduce such errors,ensuring the safety and efficacy of patients'medication.

关 键 词：中药饮片 调剂 差错 改进措施 原因分析 

分 类 号：R28[医药卫生—中药学]