美国的医疗差错报告制度及借鉴意义

准确掌握和统计医疗差错信息,对促进医疗安全有着积极意义.简要地回顾了美国医疗差错报告制度实行的概况,希望对促进我国医疗事故报告制度的建设有所借鉴.     

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。     

不同部位肿瘤患者在立体定向放射治疗中摆位误差分析及控制策略研究

目的：分析不同部位肿瘤患者在立体定向放射治疗中摆位误差,并研究其控制策略。方法：对本院2019年11月～2021年2月收治的50例肿瘤患者进行研究,所有患者进行放疗前使用KV-CBCT进行扫描,并配合六维床（Lng Lat Vrt Rtn Pitch Roll六个方向）进行校准获得图像匹配数据。对患者治疗中的摆位误差进行分析,并提出相关控制策略。结果：头部摆位误差较小,误差平均值<1mm,而胸腹部摆位误差相对较大,误差平均值>3mm,头部摆位的误差低于胸腹部,头部摆位的重复性准确率明显高于胸腹摆位;这与技师的技术、设备的精准度以及患者自身的自主和不自主运动都有非常密切的关系。结论：在肿瘤患者的立体定向放射治疗中经常会出现摆位误差的现象,因此要积极分析出现误差的原因,并进行有效的纠正和控制,提高立体定向放射治疗摆位的准确性和重复性。     

GE 1.5T核磁共振模块的故障探析

文章分析了GE 1.5T核磁共振System Support Module模块的功能及不同部位发生故障的分析及排除方法。     

Opportunities for Improving Post-Hospital Home Medication Management Among Older Adults

SUMMARY

Effective post-hospital home medication management among older adults is a convoluted, error-prone process. Older adults, whose complex medication regimens are often changed at hospital discharge, are susceptible to medication-related problems (e.g., Adverse Drug Events or ADEs) as they resume responsibility for managing their medications at home. Human error theory frames the discussion of multi-faceted, interacting factors including care system functions, like discharge medication teaching that contribute to post-hospital ADEs. The taxonomy and causes of post-hospital ADEs and related risk factors are reviewed, as we describe in high-risk older adults a population that may benefit from targeted interventions. Potential solutions and future research possibilities highlight the importance of interdisciplinary teams, involvement of clinical pharmacists, use of transitional care models, and improved use of informational technologies.     

Randomized,double-blind,placebo-controlled,safety and immunogenicity study of 4 formulations of Anthrax Vaccine Adsorbed plus CPG 7909 (AV7909) in healthy adult volunteers

A new anthrax vaccine that could accelerate the immune response and possibly reduce the number of injections needed for protection would be desirable in a post-exposure setting.     

The dosimetric impact of respiratory breast movement and daily setup error on tangential whole breast irradiation using conventional wedge,field-in-field and irregular surface compensator techniques

To evaluate the dosimetric impact of respiratory breast motion and daily setup error on whole breast irradiation (WBI) using three irradiation techniques; conventional wedge (CW), field-in-field (FIF) and irregular surface compensator (ISC). WBI was planned for 16 breast cancer patients. The dose indices for evaluated clinical target volume (CTV_evl), lung, and body were evaluated. For the anterior-posterior (AP) respiratory motion and setup error of a single fraction, the isocenter was moved according to a sine function, and the dose indices were averaged over one period. Furthermore, the dose indices were weighted according to setup error frequencies that have a normal distribution to model systematic and random setup error for the entire treatment course. In all irradiation techniques, AP movement has a significant impact on dose distribution. CTV_evlD₉₅ (the minimum relative dose that covers 95 % volume) and V₉₅ (the relative volume receiving 95 % of the prescribed dose) were observed to significantly decrease from the original ISC plan when simulated for the entire treatment course. In contrast, the D₉₅, V₉₅ and dose homogeneity index did not significantly differ from those of the original plans for FIF and CW. With regard to lung dose, the effect of motion was very similar among all three techniques. The dosimetric impact of AP respiratory breast motion and setup error was largest for the ISC technique, and the second greatest effect was observed with the FIF technique. However, these variations are relatively small.