1例用药近似错误事件的根因分析

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。

Root Cause Analysis in A Case of Similar Medication Usage Error

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.