改进药学管理系统适应医院药学的发展要求

医院药学的发展促使药剂科的工作重心从保障药品供应向以病人为中心的药学服务转变。现有医院管理系统中的药学管理系统(模块)的核心内容是药品的进、销、存,即物流、资金流的管理,为适应医院药学的发展要求,药学管理系统统需要进行改进和创新。本文从药学服务工作的三个发展方向:医院内药学信息服务、临床药师开展药学监护等工作、改进门诊和住院药品的发药模式,阐述了药学管理系统可以实现的改进和创新。     

Incidence of anesthesia-related medication errors over a 15-year period in a university hospital.

To clarify the incidence of anesthesia-related medication errors in Kyushu University Hospital, a retrospective analysis of anesthesia-related incidents from 1993 to 2007 was conducted based on the "Investigation of anesthesia-related medication incidents" by the Japanese Society of Anesthesiologists. Out of a total of 64,285 anesthesia cases, drug errors occurred in 50 cases (0.078%), but none of the incidents led to serious sequelae. Wrong medication was the most common type of drug error (48%), followed by overdose (38%), underdose (4%), omission (2%), and incorrect administration route (8%). The most commonly involved drugs were opioids, cardiac stimulants, and vasopressors. Syringe swap was the leading cause of wrong medication, accounting for 42%, drug ampoule swap occurred in 33%, and the wrong choice of drug was made in 17%. The first, second, and third most frequent causes of overdose involved a misunderstanding or preconception of the dose (53%), pump misuse (21%), and dilution error (5%). The error frequency did not decrease over the 15-year period. The responsible anesthesiologists were most likely to be doctors with a little experience. To reduce anesthesia-related medication errors, improvements of protocols for handling medication and instruction, and an improved education system for the anesthesia trainees are essential.     

Pseudomonas putida septicemia in a special care nursery due to contaminated flush solutions prepared in a hospital pharmacy

Pseudomonas putida bloodstream infections were reported in two preterm neonates from a special care nursery. An unopened container of preservative-free heparin flush, compounded several weeks earlier in the hospital pharmacy and from the same batch that was administered to the patients, grew P. putida with a pulsed-field gel electrophoresis (PFGE) pattern identical to that of the patients' isolates. Intrinsic contamination was ruled out by the absence of similar reports from other hospitals and by sterility testing of unopened stock solutions. We investigated the in vitro persistence of P. putida in heparinized saline: even under refrigerated conditions, inocula of 10(2) and 10(3) CFU/ml exhibited growth at 21 and 35 days, respectively. These findings highlight the need for compliance with current standards of aseptic technique and quality assurance during the preparation of compounded sterile products.     

PDCA循环法在医院药学教学中的应用

目的探讨“计划-执行-检查-处理”循环法(以下简称“PDCA循环法”)在医院药学教学工作中的应用效果。为加强医院药学培训、提升服务水平提供可靠参考。方法以北京朝阳医院2015年9月至2019年9月进行药学教学培训的学员为研究对象,随机抽取接受PDCA循环法药学教学培训模式的学员作为观察组,以接受传统的一般形式教学方法的学员作为对照组,对比两组研究对象在不同教学方法下的考核评分。结果观察组理论知识和操作技能评分均高于对照组(P<0.05)。结论PDCA循环法的系统化教学培训方法有利于改善学员的理论知识掌握度和操作技能,在医院药学教学中值得应用;带教导师在PDCA循环中发挥重要作用,需加强师资和制度建设;教学方法的改进有利于提高学员学习的积极性和自主性。     

The impact of a closed-loop electronic blood transfusion system on transfusion errors and staff time in a children's hospital

ObjectivesTo assess the impact of a closed-loop electronic blood transfusion system on transfusion errors and staff time.Materials and methodsBefore and after study in all wards of a children's hospital, involving patients and staff of all the wards. The changes were closed-loop electronic blood transfusion, barcode patient identification, electronic blood transfusion administration records and error pop-up warning. The main outcome measures were percentage of blood transfusion errors, time spent on transfusion tasks.ResultsTransfusion errors were identified in 3.87% of 2556 blood transfusion orders pre-intervention and 0.78% of 2577 orders afterwards (P < 0.01). Phlebotomists, nurses, and physicians may make mistakes, including wrong blood type when apply for blood, wrong patient when blood draw or transfusion, wrong dose when apply for blood and the wrong tube label when blood draw or cross-matching, which are significantly reduced after change (1.09% vs 0.31%, 1.13% vs 0%, 0.31% vs 0%, 1.33% vs.0.78%, P < 0.01). Time spent on blood apply was 5.3 ± 1.2 min, hand over blood bag at the transfusion department was 14.9 ± 1.4 min and blood transfusion was 15.8 ± 2.4 min. Time per transfusion round decreased to 2.6 ± 1.0 min, 6.3 ± 1.6 min and 9.3 ± 2.2 min respectively (P < 0.01).ConclusionsA closed-loop electronic blood transfusion, barcode patient identification and error pop-up warning reduced transfusion errors, and increased confirmation of patient and blood types identity before transfusion. Time spent on blood transfusion tasks reduced.     

Physical sources of registration errors in pulse-echo ultrasonic systems

The sources of registration errors in ultrasonic-scanning systems are discussed. In a water bath, a ball-bearing target mounted on a micromanipulator was used to find the position of maximum echo amplitude in an ultrasonic beam. A target at this location will give rise to a point on the display along the axis of the beam, and therefore deviation of this point will produce a registration error. Considerable deviations were produced by the interposing of a normal living human calf. The effects of sound velocity and absorption in the sorrounding medium were investigated. The observed deviations were attributed to the mechanisms of refraction, reflection and differential absorption.     

Topometric data presentation errors in planning systems for radiation therapy

Conclusions 1. The error of effective radiological thickness calculation in planning systems of radiation therapy was estimated for the topometric information presentation (map of patient's anatomical cross-section) as a set of contours outlining organs and tissues of uniform density. The error dependence on depth was obtained for different degrees of image detail. The error was shown to be appropriate when only lung tissue is taken into consideration. However, to reduce the error other types of tissue should be also taken into account. 2. Dose errors were also estimated for typical radiation therapy setting. Moscow Scientific-Research Institute for Diagnostics and Surgery. Translated from Meditsinskaya Tekhnika, No. 3, pp. 31–34, May–June, 1995.     

Medication errors in residential aged care facilities: A distributed cognition analysis of the information exchange process

BackgroundMedication safety is a pressing concern for residential aged care facilities (RACFs). Retrospective studies in RACF settings identify inadequate communication between RACFs, doctors, hospitals and community pharmacies as the major cause of medication errors. Existing literature offers limited insight about the gaps in the existing information exchange process that may lead to medication errors. The aim of this research was to explicate the cognitive distribution that underlies RACF medication ordering and delivery to identify gaps in medication-related information exchange which lead to medication errors in RACFs.MethodsThe study was undertaken in three RACFs in Sydney, Australia. Data were generated through ethnographic field work over a period of five months (May–September 2011). Triangulated analysis of data primarily focused on examining the transformation and exchange of information between different media across the process.ResultsThe findings of this study highlight the extensive scope and intense nature of information exchange in RACF medication ordering and delivery. Rather than attributing error to individual care providers, the explication of distributed cognition processes enabled the identification of gaps in three information exchange dimensions which potentially contribute to the occurrence of medication errors namely: (1) design of medication charts which complicates order processing and record keeping (2) lack of coordination mechanisms between participants which results in misalignment of local practices (3) reliance on restricted communication bandwidth channels mainly telephone and fax which complicates the information processing requirements. The study demonstrates how the identification of these gaps enhances understanding of medication errors in RACFs.ConclusionsApplication of the theoretical lens of distributed cognition can assist in enhancing our understanding of medication errors in RACFs through identification of gaps in information exchange. Understanding the dynamics of the cognitive process can inform the design of interventions to manage errors and improve residents’ safety.     

Experience of changing between signal and Bactec 9240 blood culture systems in a children's hospital.

AIM: To compare experience of positive blood cultures in successive years before and after changing from Signal (Unipath) to Bactec 9240 (Becton Dickinson) blood culture systems. METHODS: Analysis of data collected prospectively on 7967 Signal and 7062 Bactec blood culture sets. RESULTS: Significant growths occurred in 5.7% of Signal and 8.9% of Bactec cultures; 33.0% more significant isolates and 24.0% more episodes of bacteraemia were detected in the second year, following introduction of the Bactec system. Inpatient hospital activity increased by 8.2% between the first and second years, although the numbers of blood cultures received actually fell by 11.4%. There were striking increases in numbers of isolates of coagulase negative staphylococci (47.7%) and Enterobacteriaceae (56.8%) from Bactec cultures. Two anaerobic bacteraemias were detected in Signal blood cultures, whereas none was detected by the Bactec system, despite 12.1% of sets including an anaerobic bottle. Of significant positive cultures, 90.2% were detected within one day with the Bactec 9240, compared with only 50.0% of Signal cultures; 20.7% of significant positive Signal blood cultures were detected only on terminal subculture. Microorganisms that were not significant were isolated from 5.1% Signal and 3.8% Bactec cultures. CONCLUSIONS: Compared with the Signal system, the Bactec 9240 offers markedly more rapid and sensitive detection of bacteraemia, together with a lower rate of non-significant isolates. However, using a single PEDS PLUS/F bottle the few episodes of anaerobic bacteraemia that occur in children are likely to be missed.     

Pneumatic tube net conveying systems in the hospital environment

The primary aim for having recourse to a pneumatic tube net to convey blood samples, is to shorten the turn around time in which transport delay is the major issue: this represents the logical answer to this question, as opposed to point of care testing. It also permits saving in transport personnel. It is of the highest importance of having recourse only to a high quality equipment (robust, reliable) likely to face the heavy workload occurring in a hospital environment, avoiding the use of light structures primarily designed for cash remittance. Implanting such a net in newly constructed structures is generally easy, while connecting the net into old buildings might meet some space limiting difficulties. Detailed prior planning of the network is a major issue for success.     

A study of hospital based ambulance systems in Wisconsin

This study was undertaken to determine the advantages and disadvantages of a hospital-based emergency medical service system with hospital employees serving as emergency medical technicians. This type of service is operating in thirteen hospitals in Wisconsin. A series of interviews was conducted to obtain pertinent information regarding the hospital, emergency medical vehicles, ambulance attendants, finances, communications and personal reactions to the system. The data indicate that hospital-based services using hospital employees can operate with minimal interference to regular patient care, and with apparent advantages to the emergency patients. In the rural, sparsely populated areas which were studied, response times from the hospital-based systems were comparable to other rural systems, and the financial and administrative aspects of the system were reviewed.