医疗失效模式与效应分析结合根本原因分析在代煎中药质量管理中的应用  

Application of healthcare failure mode and effect analysis combined with root cause analysis in quality management of decocted traditional Chinese medicine

作　　者：鞠晓宇 赵越 唐贺[1] 于伟莉[1] 陈迎春[1] 关胜江[4] 程杰[1] JU Xiaoyu;ZHAO Yue;TANG He;YU Weili;CHEN Yingchun;GUAN Shengjiang;CHENG Jie(Department of Pharmacy,Hebei Provincial Hospital of Chinese Medicine,Hebei Shijiazhuang 050011,China;Depart-ment of Pharmacy,Hebei General Hospital,Hebei Shijiazhuang 050054,China;Hebei Key Laboratory of Clinical Phar-macy,Hebei Shijiazhuang 050054,China;Dean office,Hebei Provincial Hospital of Chinese Medicine,Hebei Shijiazhuang 050011,China)

机构地区：[1]河北省中医院药学部,河北石家庄050011 [2]河北省人民医院药学部,河北石家庄050054 [3]河北省临床药学重点实验室,河北石家庄050054 [4]河北省中医院院长办公室,河北石家庄050011

出　　处：《中国医院药学杂志》2025年第3期331-336,共6页Chinese Journal of Hospital Pharmacy

基　　金：河北省中医药管理局科研计划项目(编号:2025216)。

摘　　要：目的:探讨医疗失效模式与效应分析(healthcare failure mode and effect analysis,HFMEA)结合根本原因分析(root cause analysis,RCA)在代煎中药质量管理中的应用效果。方法:组建分析团队,运用HFMEA分析代煎中药质量管理流程中的潜在失效模式,采用柏拉图确定关键潜在失效模式,再应用RCA法找出根本原因,拟定相应改进措施并评估干预后的效果。结果:改进措施干预后,6项关键潜在失效模式的风险优先级数(risk priority number,RPN)值均显著下降(P<0.05);各环节工作差错率由0.10%降至0.03%(χ^(2)=46.66,P<0.0001);投诉事件占比由0.07‰降至0.007‰(χ^(2)=6.711,P=0.0096);满意度评分由3.10升至4.23(P<0.01)。结论:采用HFMEA联合RCA法用于代煎中药管理可有效降低差错发生,提高患者与药师满意度,保障患者用药安全。OBJECTIVE To discuss the effect of healthcare failure mode and effect analysis(HFMEA)combined with root cause analysis(RCA)in quality management of decocted traditional Chinese medicine(TCM).METHODS An analysis team was created to analyze potential failure modes in the quality management process of decocted TCM by HFMEA.The key potential failure modes were determined by the Plato.RCA was conducted to identify the root cause,formulate corresponding control measures,and evaluate the effectiveness of implementation.RESULTS After the implementation of improvement measures,the risk priority number(RPN)of the six key potential failure modes significantly decreased(P<0.05).The error rate in each stage of work significantly decreased from 0.10%to 0.03%(χ^(2)=46.66,P<0.0001).The proportion of complaints significantly decreased from 0.07‰to 0.007‰(χ^(2)=6.711,P=0.0096).The satisfaction score significantly increased from 3.10 to 4.23(P<0.01).CONCLUSION HFMEA combined with RCA for the management of decocted TCM can effectively reduce errors,improve patient and pharmacist satisfaction,and ensure patient medication safety.

关 键 词：医疗失效模式与效应分析 根本原因分析 煎药中心 质量管理 中药煎药 

分 类 号：R977[医药卫生—药品]