1例给药错误的根本原因分析
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摘要
针对1例给药错误不良事件,成立RCA团队,完成事件回顾性描述,应用鱼骨图查找近端原因,运用五问法剖析根本原因,制定改进措施并落实。通过完善相似药品管理制度,细化口服药给药流程,落实双向核对制度,加强低年资护士培训与管理,可杜绝相似药品口服给药错误事件再发生。
For one case of adverse event by improper medicine administration,the root cause analysis(RCA)team was established to complete the retrospective description of the event,apply the fishbone diagram to find the near-end cause,use the five-question method to analyze the root cause,and formulate improvement measures and implement them.Through the improvement of similar drug management system,the oral drug administration process can be refined,the two-way check system will be implemented,and the training and management of low-grade nurses can be strengthened to prevent the recurrence of oral drug misfeeds of similar drugs.
For one case of adverse event by improper medicine administration,the root cause analysis(RCA)team was established to complete the retrospective description of the event,apply the fishbone diagram to find the near-end cause,use the five-question method to analyze the root cause,and formulate improvement measures and implement them.Through the improvement of similar drug management system,the oral drug administration process can be refined,the two-way check system will be implemented,and the training and management of low-grade nurses can be strengthened to prevent the recurrence of oral drug misfeeds of similar drugs.
引文
[1]World Health Organization,Regional Office for Africa.Guide for developing national patient safety policy and strategic plan[EB/OL].(2014-12-10)[2014-12-24].http://www.who.int/iris/handle/10665/148352.
[2]万文洁,田梅梅,施雁.护士给药错误管理研究现状[J].中国护理管理,2012,12(7):45-48.
[3]Barber N D,Alldred D P,Raynor D K,et al.Care homes'use of medicines study:prevalence,causes and potential harm of medication errors in care homes for older people[J].QualSaf Health Care,2 0 0 9,1 8(5):341-346.
[4]林峰.PDCA循环在化疗药物安全管理中的应用[J].中国医药导报,2015,12(8):147-151.
[5]张霞.根本原因分析法在给药错误事件管理中的应用[J].齐鲁护理杂志,2016,22(3):103-105.
[6]唐新,贾克刚,李秀良,等.1例血小板输错事件的根本原因分析[J].中国卫生质量管理,2016,23(2):13-15.
[7]滕苗,肖明朝,吕富荣,等.什么是RCA2[J].中国卫生质量管理,2016,23(2):16-18.
[8]谢树英.1例行MRI检查导致胰岛素泵磁化不良事件的根因分析[J].中国卫生质量管理,2017,24(5):53-55,66.
[9]尹晓红.运用PDCA管理降低护士用药不良事件发生率[J].护理实践与研究,2017,14(18):108-109.
[10]中国医院协会.中国医院协会患者安全目标(2017版)[EB/OL].(2016-12-26).http://www.cha.org.cn/plus/view.php?aid=15131.
[11]黄婷婷,李艳双,焦明丽,等.采用根因分析法降低手术患者病理标本送检差错率的实践[J].中国护理管理,2015,15(4):471-474.
[2]万文洁,田梅梅,施雁.护士给药错误管理研究现状[J].中国护理管理,2012,12(7):45-48.
[3]Barber N D,Alldred D P,Raynor D K,et al.Care homes'use of medicines study:prevalence,causes and potential harm of medication errors in care homes for older people[J].QualSaf Health Care,2 0 0 9,1 8(5):341-346.
[4]林峰.PDCA循环在化疗药物安全管理中的应用[J].中国医药导报,2015,12(8):147-151.
[5]张霞.根本原因分析法在给药错误事件管理中的应用[J].齐鲁护理杂志,2016,22(3):103-105.
[6]唐新,贾克刚,李秀良,等.1例血小板输错事件的根本原因分析[J].中国卫生质量管理,2016,23(2):13-15.
[7]滕苗,肖明朝,吕富荣,等.什么是RCA2[J].中国卫生质量管理,2016,23(2):16-18.
[8]谢树英.1例行MRI检查导致胰岛素泵磁化不良事件的根因分析[J].中国卫生质量管理,2017,24(5):53-55,66.
[9]尹晓红.运用PDCA管理降低护士用药不良事件发生率[J].护理实践与研究,2017,14(18):108-109.
[10]中国医院协会.中国医院协会患者安全目标(2017版)[EB/OL].(2016-12-26).http://www.cha.org.cn/plus/view.php?aid=15131.
[11]黄婷婷,李艳双,焦明丽,等.采用根因分析法降低手术患者病理标本送检差错率的实践[J].中国护理管理,2015,15(4):471-474.