[1]姚丽丽 李跃荣 赵庆华 肖明朝.1例用药近似错误事件的根因分析[J].中国卫生质量管理,2020,27(01):086-89.[doi:10.13912/j.cnki.chqm.2020.27.1.22]
点击复制

1例用药近似错误事件的根因分析
分享到：

《中国卫生质量管理》[ISSN:1006-7515/CN:CN 61-1283/R]

卷:
第27卷
期数:
2020年01期
页码:
086-89
栏目:
患者安全
出版日期:
2020-01-28

文章信息/Info

作者:
姚丽丽 李跃荣 赵庆华 肖明朝
重庆医科大学附属第一医院
关键词:
根本原因分析; 用药安全; 用药近似错误; 不良事件; 患者安全
Keywords:
Root Cause Analysis; Medication Safety; Similar Medication Usage Error; Adverse Events; Patient Safety
DOI:
10.13912/j.cnki.chqm.2020.27.1.22
摘要:
通过根本原因分析法，对1例潜在严重后果的手术患者止血药物近似错误案例进行剖析，探讨医嘱管理、相似药品、沟通不良、药物相关知识缺乏、惯性思维等对安全用药的影响。口头指示不清或不明可能导致用药错误，口头医嘱存在较高风险；医护人员用药知识不丰富是医嘱错误常见原因之一；系统不完善可能导致用药差错。确保用药安全需要优化制度流程，加强临床医务工作者的有效沟通与协作，强化医务人员角色功能定位以及完善系统等。
Abstract:
Through root cause analysis, a case of similar medication usage error of hemostatic medication in surgery patient with potential serious consequence was analyzed, and the effects of medical order management, similar medication, poor communication, lack of medication-related knowledge and habitual thinking on safe medication were discussed.The unclear oral instructions might lead to medication errors, and there was a risk of errors in oral instructions. Inadequate knowledge of medication was one of the common reasons for errors in medical order and incomplete system might lead to medication errors.To ensure medication safety, it was necessary to optimize the system flow, strengthen the effective communication and cooperation of clinical medical workers, enhance the role function of medical staff and improve the system.

参考文献/References:

［1］WHO.Medication without Harm: WHO's Third Global Patient Safety Challenge［EB/OL］.（2017-05-06）.http://www.who.int/patientsafety/medication-safety/en/.

相似文献/References:

[1]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(02):013.[doi:10.13912/j.cnki.chqm.2016.23.2.05]
[2]侯杰 王欣 董军.静脉用药安全调配闭环管理的设计与实现[J].中国卫生质量管理,2017,24(03):007.[doi:10.13912/j.cnki.chqm.2017.24.3.03]
[3]张叶 王欣 董军.一例儿童停跳液质量不合格的根本原因分析[J].中国卫生质量管理,2017,24(03):048.[doi:10.13912/j.cnki.chqm.2017.24.3.17]
[4]王跃建 曾勇 章成国 陈国强 廖珊 周之昊.基于根本原因分析法的不良事件改进[J].中国卫生质量管理,2018,25(03):007.[doi:10.13912/j.cnki.chqm.2018.25.3.03]
[5]李梦玲 王富兰 肖明朝 赵庆华 沈馨 江颖.1例给药错误的根本原因分析[J].中国卫生质量管理,2019,26(02):058.[doi:10.13912/j.cnki.chqm.2019.26.2.18]
[6]张镭 商永光 郭冬杰 张翠翠 邓昂 唐崑 陆进.应用美国用药安全自我测评量表改进用药安全[J].中国卫生质量管理,2020,27(03):079.
　ZHANG Lei,SHANG Yongguang,GUO Dongjie,et al.Using the American Medication Safety Self-Assessment Scale to Improve Medication Safety[J].Chinese Health Quality Management,2020,27(01):079.
[7]吴倩 刘红玲 翟谢民 庞浩.1例自备药用药错误的分析与改进[J].中国卫生质量管理,2020,27(05):076.
　WU Qian,LIU Hongling,ZHAI Xiemin,et al.Analysis and Improvement of One Case of Medication Error of Self-Contained Medicine[J].Chinese Health Quality Management,2020,27(01):076.
[8]钟林涛李朋梅张镭芦宏凯孙阳.患者安全目标：确保用药与用血安全[J].中国卫生质量管理,2020,27(06):005.[doi:10.13912/j.cnki.chqm.2020.27.6.02 ]
　ZHONG Lintao,LI Pengmei,ZHANG Lei,et al.Patient Safety Goal:To Ensure the Safety of Medication and Blood Use[J].Chinese Health Quality Management,2020,27(01):005.[doi:10.13912/j.cnki.chqm.2020.27.6.02 ]
[9]谢大玲李君慧肖代梅袁偲旖侯静张方玲陈航.1例晨间集中静脉血标本采集错误的根因分析与改进[J].中国卫生质量管理,2021,28(02):047.[doi:10.13912/j.cnki.chqm.2021.28.2.15 ]
　XIE Daling,LI Junhui,XIAO Daimei.Root Cause Analysis and Improvement of an Incident of Erroneous Collection of Venous Blood Samples in the Morning[J].Chinese Health Quality Management,2021,28(01):047.[doi:10.13912/j.cnki.chqm.2021.28.2.15 ]
[10]刘彦君王宁丽余新华王静上官红梅师卓维.1例非机械通气患者人工气道痰液堵塞致窒息事件根本原因分析[J].中国卫生质量管理,2021,28(11):068.[doi:10.13912/j.cnki.chqm.2021.28.11.16 ]
　LIU Yanjun,WANG Ningli,YU Xinhua.Root Cause Analysis of Asphyxia Caused by Sputum Blockage in Artificial Airway in a Non-Mechanical Ventilation Patient[J].Chinese Health Quality Management,2021,28(01):068.[doi:10.13912/j.cnki.chqm.2021.28.11.16 ]

更新日期/Last Update: 2020-01-28