儿童洋地黄中毒事件的药学风险点挖掘及防范措施效果研究

目的：降低儿童服用地高辛导致洋地黄中毒风险发生率，保证用药安全。方法：运用追踪方法学对监测中发现的儿童洋地黄中毒案例进行个案追踪，找出可能存在的风险点，再运用系统追踪法，剖析系统或流程中的潜在风险，制定对策，持续改进，并评价追踪前后的管理效果。结果：个案追踪发现儿童洋地黄中毒风险点主要是药物剂量和合并用药，系统追踪发现存在药品因素、人员因素和信息系统因素等导致的风险。通过系列控制风险措施的实施，追踪后再未发生儿童洋地黄中毒事件和超说明书剂量医嘱，治疗药物监测（TDM）监测率和治愈率追踪后较追踪前有明显提高（P<0.05）。结论：药师运用追踪方法学进行儿童洋地黄中毒风险点的挖掘和防范措施的实施，可降低儿童洋地黄中毒事件发生率，保障儿童用药安全

Pharmaceutical Risk Points and Preventive Measures of Digitalis Poisoning in Children

Objective: To reduce the risk of digitalis poisoning induced by digoxin in children, so as to ensure the safety of medication. Methods: The tracer methodology was used to track the case of digitalis poisoning in children, the possible risk points were find out, the potential risks in the system or process were analyzed, and corresponding countermeasures were formulated for continuous improvement, and the management effects before and after the tracking were evaluated. Results: Individual tracer activity found that the main risk points of digitalis poisoning in children were drug dosage and combination of drugs. System tracer activity showed that there were risks induced by drug factors, personnel factors and information system factors. Through the implementation of risk control countermeasures, there were no digitalis poisoning in children and off-label instructions in medical orders after the follow-up. After tracer methodology, the monitoring rate and cure rate of therapeutic drug monitoring (TDM) were significantly higher than those before tracer methodology (P<0.05). Conclusion: The incidence of digitalis poisoning in children can be reduced and the medication safety can be ensured through applying tracking methodology for the identification of risk points and implementation of preventive measures by pharmacists