基层医院药房用药差错原因分析与持续改进

目的找出医院药房用药差错发生的原因,认真进行分析,提出防范措施,减少或杜绝用药差错的发生,确保用药安全有效。方法通过对医院药房用药差错情况进行分析、归纳、总结,结合自己的工作经验,提出切实可行的用药差错防范措施。结果药房用药差错在药品的管理和使用各个环节都有可能发生,有众多方面原因,而药房药师是用药差错的主要因素。结论通过对医院药房用药差错原因的分析,采取综合性防范措施,可以减少或杜绝用药差错的发生,保证用药安全有效。     

基层医院门诊药房用药错误的调查分析和预防对策

目的探讨医院门诊药房的用药错误预防对策,为规范药房管理提供借鉴。方法对医院门诊药房2009年至2011年292例用药错误具体原因进行调查分析。结果292例用药错误中,药师调配差错有181例,占61．99％：医师处方差错111例,占38．01％。结论引起门诊药房用药错误的原因很多,应努力完善管理措施,提高医务人员业务水平,以减少用药错误,保证患者用药安全。     

医院药房药品差错的常见问题及管理对策

目的对医院药房药品差错的常见问题进行分析,总结相应的管理对策。方法对我院药房药品差错的原因进行调查分析,并根据调查分析结果和文献报道总结相应的管理对策。结果医院药房药品差错涉及到药品调剂、管理和对患者的指导三方面,为预防和减少医院药房药品差错的发生,应在制度、人员、环境等多个方面加强管理。结论医院药房药品差错存在与医院药房工作的各个环节,医院应加强管理,防止医院药房药品差错的发生。     

药房常见差错及日常管理

医院药房是医院重要组成部分之一,主要负责医院所需各种药品的调剂和供应,提供相关用药咨询和指导服务。在医院的医疗、科研等方面,均发挥着无可替代的重要作用。加强药房质量管理,是杜绝和减少药房差错事故发生的必要手段。目前药房管理工作中常见的差错类型有医生处方不当、剂量错误、随意给药、给药次数有误、药物剂型差错、给药时间出错、药物变质、药物服用方法差错等。这些差错给患者带来很大安全隐患。结合当前差错的主要类型及原因,本文从药品管理、制度管理、人员管理以及做好药品用药前咨询工作等方面着手,来减少和避免药房日常差错,提高患者用药安全性。     

我院药房内部差错管理的体会

本文探讨了药房内部差错的概念、意义和防范措施。结合和睦家医院目前药房内部差错管理的现状,介绍我院在药房内部差错管理方面的经验,以期为其它医院用药差错监测和干预提供参考。     

PDCA循环在住院药房调剂差错管理中的运用

目的探讨PDCA循环法在郑州大学附属肿瘤医院住院药房调剂差错中的应用。方法对2013年4—9月份郑州大学附属肿瘤医院住院药房运用PDCA循环法前后调剂差错进行回顾性的对比分析。结果运用PDCA循环法之后,住院药房调剂差错的总件数有了明显下降。结论运用PDCA循环法对住院药房调剂差错进行管理具有显著的效果,能够提高住院药房的调剂质量,确保患者的用药安全。     

加强管理减少门诊药房调剂差错

门诊药房是医院面向社会和患者的一个重要窗口,是医院提供药物治疗服务的关键环节,其药学服务质量的优劣,直接影响患者的健康。因此,加强管理、减少调剂差错,保证临床用药安全,提高门诊药房的调剂工作质量非常重要。笔者分析了调剂差错原因,并提出防止调剂差错的管理措施。     

浅谈药房调剂差错原因分析及对策

药房是医院面向患者服务的重要窗口,其服务质量的优劣直接影响到医院在患者心目中的形象。加强药房管理,全面提高药房的人性化服务水平,减少或杜绝药品调剂差错,保证患者用药安全、合理、有效,是我们每个医务人员应该思考和关注的问题。现针对我院药房调剂差错的类型和原因进行分析,并提出相应对策。     

药房管理中处方差错分析与预防

药房发药是医疗服务环节中关键的一环,配药发药过程中的处方差错往往是导致医疗纠纷的重要因素之一。药房处方差错的发生不仅影响医院的形象和发展,而且关系着患者的健康和生命安全。本文结合作者在药房实际工作的经验和体会,就药房管理中出现处方差错的原因进行分析和总结,最后就如何减少药房处方差错、保证用药安全提出应对措施。     

用全面质量管理方法分析和控制医院门诊药房调剂差错

目的使用全面质量管理方法分析和控制医院门诊药房调剂差错。方法使用全面质量管理方法从机器、材料、人、方法、环境分别对78例医院门诊药房调剂差错事故进行因果分析。结果影响医院门诊药房调剂差错事故中,＂人＂是最重要的因素,占82.1%。围绕＂人＂这一主要因素进行控制可减少药房调剂差错。医院门诊药房调剂差错由原来的每年平均20例降低到2013年全年仅发生2例。结论全面质量管理方法可降低医院门诊药房调剂差错。     

Policies on documentation and disciplinary action in hospital pharmacies after a medication error.

Hospital pharmacies were surveyed about policies on medication error documentation and actions taken against pharmacists involved in an error. The survey was mailed to 500 randomly selected hospital pharmacy directors in the United States. Data were collected on the existence of medication error reporting policies, what types of errors were documented and how, and hospital demographics. The response rate was 28%. Virtually all of the hospitals had policies and procedures for medication error reporting. Most commonly, documentation of oral and written reprimand was placed in the personnel file of a pharmacist involved in an error. One sixth of respondents had no policy on documentation or disciplinary action in the event of an error. Approximately one fourth of respondents reported that suspension or termination had been used as a form of disciplinary action; legal action was rarely used. Many respondents said errors that caused harm (42%) or death (40%) to the patient were documented in the personnel file, but 34% of hospitals did not document errors in the personnel file regardless of error type. Nearly three fourths of respondents differentiated between errors caught and not caught before a medication leaves the pharmacy and between errors caught and not caught before administration to the patient. More emphasis is needed on documentation of medication errors in hospital pharmacies.     

我院用药差错与临界差错事件分析与整改措施

目的:探讨用药差错与临界差错事件发生的原因及对策,为减少医院的用药错误提供依据。方法:基于我院2017年1月至2018年9月不良事件信息平台上报的277例用药差错与临界差错事件的数据汇总,从差错环节、差错类别及差错人三个方面进行数据分析,提出改进措施、减少用药差错。结果:针对导致差错的原因优化系统管理、加强培训、进行PDCA质量改进,持续改进固化流程,修改制度与流程。结论:通过用药差错与临界差错的原因分析及质量改进,有效防范用药差错事件的发生,最大限度减少用药差错,促进临床合理用药,确保患者安全用药。     

医院用药差错的系统分析与对策

目的:分析某省级三甲医院药疗实践中出现的用药差错情况,提高药学服务水平和药师调剂质量,减少医疗安全隐患,促进医院医疗质量提升。方法:汇总该院2012年9月1日-2013年8月31日出现的用药差错,采用美国国家用药差错报告和预防协调委员会(NCC-MERP)用药差错分级方法进行汇总,分析用药差错产生的原因,提出适当的防范措施和对策。结果:本研究共收集332例用药差错,占总调剂总量的0.11‰。按照不同分类方法汇总分析发现:98.2%(326)的差错未造成患者伤害;内部差错与出门差错比例为291:41;差错发生率最高的为药师调配数量差错,占到33.4%;鱼骨图分析得出人、事、物为造成调配数量差错的三个主要原因。结论:用药差错是客观存在的,医院应当在建立现代的非惩罚性用药差错事件上报制度上,采取鼓励措施促使医务人员积极自愿上报用药差错事件,并利用质量管理工具全面分析和防范用药差错。     

某院住院药房818例用药错误分析及对策

目的 分析北京大学国际医院（以下简称“我院”）住院药房用药错误的发生情况,探讨提高患者用药安全的应对策略,提出降低差错发生的对策。方法 利用查阅法、回顾性统计分析法对我院2019年11月～2021年6月病房药房登记的用药错误记录进行研究,分析差错原因、归纳相关原因。结果 按错误发生环节统计,共收集到818例用药错误,均为未出门差错。在用药错误分级管理中A级71例、B级747例,无C级以上用药错误。用药错误分类中全部来自调剂差错,差错类型例数由高到低依次是：药品数量325例次,药品种类322例次,其他94例次,药品规格59例次,药品剂型19例次。结论 引起调配差错的因素是多方面的,应针对本医疗机构出现的用药风险隐患开展持续改进,提升医院用药安全为目的,全程防范,闭环管理。     

我中心用药错误情况分析

目的：了解我中心用药错误情况,为规范医院用药提供对策参考。方法：依据相关文献和资料对我中心用药错误的情况进行分类、统计和分析,并提出合理的对策。结果：目前我中心用药错误情况主要包括扩大适应证、超常规剂量用药及不合理配伍用药等情况。结论：建议采取制定相关管理办法、加强医护人员培训等方法来减少或避免用药错误情况的发生。     

Medication errors when transferring elderly patients between primary health care and hospital care

Objective: The aims were to evaluate the frequency and nature of errors in medication when patients are transferred between primary and secondary care.Method: Elderly primary health care patients (> 65years) living in nursing homes or in their own homes with care provided by the community nursing system, had been admitted to one of two hospitals in southern Sweden, one university hospital and one local hospital. A total of 69 patient-transfers were included. Of these, 34 patients were admitted to hospital whereas 35 were discharged from hospital.Main outcome measure: Percentage medication errors of all medications i.e. any error in the process of prescribing, dispensing, or administering a drug, and whether these had adverse consequences or not.Results: There were 142 medication errors out of 758 transfers of medications. The patients in this study used on an average more than 10 drugs before, during and after hospital stay. On an average, there were two medication errors each time a patient was transferred between primary and secondary care. When patients were discharged from the hospital, the usage of a specific medication dispensing system constituted a significant risk for medication errors. The most common error when patients were transferred to the hospital was inadvertent withdrawal of drugs. When patients left the hospital the most common error was that drugs were erroneously added.Conclusion: Medication errors are common when elderly patients are transferred between primary and secondary care. Improvement in documentation and transferring data about elderly patients medications could reduce these errors. The specific medication dispensing system that has been used in order to increase safety in medication dispensing does not seem to be a good instrument to reduce the number of errors in transferring data about medication.     

Clinical outcomes from the use of Medication Report when elderly patients are discharged from hospital

Objective The objective of this study was to investigate whether a Medication Report also can reduce the number of patients with clinical outcomes due to medication errors. Method A prospective intervention study with retrospective controls on patients at three departments at Lund University Hospital, Sweden that where transferred to primary care. The intervention group, where patients received a Medication Report at discharge, was compared with a control group with patients of the same age, who were not given a Medication Report when discharged from the same ward one year earlier. For patients with at least one medication error all contacts with hospital or primary care within 3 months after discharge were identified. For each contact it was evaluated whether this was caused by the medication error. We also compared medication errors that have been evaluated as high or moderate clinical risk with medication errors without clinical risk. Main outcome measures Need for medical care in hospital or primary care within three months after discharge from hospital. Medical care is readmission to hospital as well as visits of study population to primary and out-patient secondary health care. Results The use of Medication Report reduced the need for medical care due to medication errors. Of the patients with Medication Report 11 out of 248 (4.4%) needed medical care because of medication errors compared with 16 out of 179 (8.9%) of patients without Medication Report (p = 0.049). The use of a Medication Report significantly reduced the risk of any consequences due to medication errors, p = 0.0052. These consequences included probable and possible care due to medication error as well as administrative procedures (corrections) made by physicians in hospital or primary care. Conclusions The Medication Report seems to be an effective tool to decrease adverse clinical consequences when elderly patients are discharged from hospital care.     

What should a pharmacy manager do when a serious medication error occurs? A panel discussion.

Questions related to medication errors were discussed by a panel of hospital department managers. When a serious medication error occurs, the manager has a responsibility to help the employee, the patient, and the patient's family cope with its effects, as well as a responsibility to prevent such errors from recurring. The difficulty of dealing with medication errors may be compounded when the legal system and the news media get involved. Therefore, a system for handling a serious error should be in place before that error occurs. It is also necessary to decide whether to use medication error reports in the employee evaluation process; this could make employees reluctant to report their errors. Ultimately, pharmacy managers are responsible for medication errors that occur, and repercussions have varied from nothing to reprimands to termination. Past errors, if they are reported, can be used to improve the system in which they occurred and to educate other health-care professionals. Therefore, pharmacists need to cooperate with other health-care professionals in documenting medication error reports. A national reporting system is needed so that medication error information can be shared on a large scale without placing the people involved in legal jeopardy. Sharing information about medication errors is necessary to prevent future occurrences; mechanisms are needed to facilitate such sharing.     

英国用药错误管理机制及其对我国的启示

探索英国用药错误管理的相关模式与制度,为我国的相关管理工作提供参考.研读中英两国用药错误管理的相关指南与政策文件,重点关注两国用药错误在发现、处理、上报、分析等环节的差异,以寻求完善我国用药错误管理的途径与方法.英国用药错误管理的相关政策已达成熟、细化,尤其在用药错误的报告及分析方面值得借鉴,以不断完善我国的相关制度与...