[1]何芳王富兰谢莉玲肖明朝凌舒娅.基于TeamSTEPPS的两例胰岛素用药错误原因分析及改进[J].中国卫生质量管理,2022,29(07):71-74.[doi:10.13912/j.cnki.chqm.2022.29.7.18 ]
　HE Fang,WANG Fulan,XIE Liling.Root Cause Analysis and Improvement of Two Cases of Incorrect Dosage of Insulin Based on TeamSTEPPS[J].Chinese Health Quality Management,2022,29(07):71-74.[doi:10.13912/j.cnki.chqm.2022.29.7.18 ]

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基于TeamSTEPPS的两例胰岛素用药错误原因分析及改进

《中国卫生质量管理》[ISSN:1006-7515/CN:CN 61-1283/R] 卷: 第29卷期数: 2022年07期页码: 71-74 栏目: 患者安全出版日期: 2022-07-28

Title:: Root Cause Analysis and Improvement of Two Cases of Incorrect Dosage of Insulin Based on TeamSTEPPS

作者:: 何芳王富兰谢莉玲肖明朝凌舒娅; 重庆医科大学附属第一医院

Author(s):: HE Fang; WANG Fulan; XIE Liling; The First Affiliated Hospital of Chongqing Medical University

关键词:: 根本原因分析法; 胰岛素; TeamSTEPPS; 用药安全

Keywords:: Root Cause Analysis; Insulin; TeamSTEPPS; Medication Safety

分类号:: R197.323;R977.1+5

DOI:: 10.13912/j.cnki.chqm.2022.29.7.18

文献标志码:: B

摘要:: 针对两例典型的胰岛素注射液用药错误不良事件进行根本原因分析并予以改进。通过实施基于TeamSTEPPS建立的胰岛素模块化教学体系，优化医嘱处理流程，将皮下注射的胰岛素按高警示药品监管，对患者加强健康教育及效果评价等，类似不良事件未再次发生。

Abstract:: The root cause analysis was carried out for two typical cases of adverse events on incorrect dosage of insulin injection, and targeted improvement was carried out. By measures of implementing the system of insulin modularized teaching based on TeamSTEPPS, optimizing the process of doctor's order, monitoring the hypodermic insulin as high warning drug, and strengthening health education and effect evaluation of patients, the similar adverse events had not occurred again.

参考文献/References:

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更新日期/Last Update: 2022-07-28