[1]郑美徐步龙李浩.1例新生儿葡萄糖注射液浓度错误的解析与改进[J].中国卫生质量管理,2021,28(04):052-54.[doi:10.13912/j.cnki.chqm.2021.28.4.15 ]
 ZHENG Mei,XU Bulong,LI Hao.Analysis and Improvement of a Concentration Error of Neonatal Glucose Injection[J].Chinese Health Quality Management,2021,28(04):052-54.[doi:10.13912/j.cnki.chqm.2021.28.4.15 ]
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1例新生儿葡萄糖注射液浓度错误的解析与改进
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《中国卫生质量管理》[ISSN:1006-7515/CN:CN 61-1283/R]

卷:
第28卷
期数:
2021年04期
页码:
052-54
栏目:
患者安全
出版日期:
2021-04-28

文章信息/Info

Title:
Analysis and Improvement of a Concentration Error of Neonatal Glucose Injection
作者:
郑美徐步龙李浩
上海交通大学医学院附属上海儿童医学中心
Author(s):
ZHENG MeiXU BulongLI Hao
Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine
关键词:
新生儿高浓度葡萄糖剂量错误处方审核调配患者安全
Keywords:
NewbornHigh Concentration Glucose Dosage Error Prescription Review Dispensing Patient Safety
分类号:
R197.323;R95
DOI:
10.13912/j.cnki.chqm.2021.28.4.15
文献标志码:
B
摘要:
对1例新生儿高浓度葡萄糖注射液浓度错误案例进行解析,制定处方审核制度,完善静脉注射用药成品浓度上限表和处方前置审核中高浓度葡萄糖的浓度限制信息,优化调剂药师处置流程,强化调剂岗位相关知识培训等措施并予以实施,避免了此类事件再次发生,确保了患者安全,提升了临床合理用药水平。
Abstract:
An incorrect case of neonatal high concentration glucose injection was analyzed. Measures were taken including formulating prescription review system, improving the upper limit table of concentration of drugs by intravenous injection, improving the concentration limit information of high concentration glucose in the pre-trial prescription,optimizing the disposal process of dispensed pharmacists, improving the relevant knowledge training of the dispensing department.The recurrence of such incidents was avoided, the safety of patients was ensured, and the level of clinical rational drug use was improved.

参考文献/References:

[1]Fradkin EC,Lafferty MA,Greenspan JS,et al. Neonatal intensive care unit admissions before and after the adoption of the baby friendly hospital initiative[J].J Matern Fetal Neona,2020(12):1-6. [2]王学贤,陈敏玲,李浩,等. 基于JCI的儿童医院门急诊输液药房药品冲配绩效模型研究[J].中国药师,2018,21(1):154-156,185. [3]Queensland Clinical Guideline. Queensland Clinical Guideline: Hypoglycaemia-newborn[RB/OL]. (2019).https://www.health.qld.gov.au/_data/assets/pdf_file/0043/881899/g-hypogly.pdf. [4]李浩,施芳红,黄诗颖,等. 基于第六版JCI标准的门急诊输液应急预案构建[J].中国卫生质量管理,2019,26(3):44-46. [5]黄忠利,陈蕾,张建强,等. 药物性静脉炎的预防和治疗的护理进展[J].中国医药导报,2018,15(33):32-35. [6]赵方允,丁莉,王丽,等. 275种常用静脉滴注药物浓度与滴速分析[J].中国医院药学杂志,2017,37(14):1405-1408. [7]沈双双,施芳红,李浩,等. 应用HIMSS 6级标准构建药品追溯体系[J].中国卫生质量管理,2019,26(5):89-92. [8]王海剑,顾艳. 高危药品安全管理实践[J].中国卫生质量管理,2015,22(4):39-42.

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更新日期/Last Update: 2021-04-28