风险管理在胰岛素及其类似物用药错误防范中的应用

目的：加强胰岛素及其类似物（以下简称胰岛素）的药品使用风险管理，保障患者用药安全。方法：借鉴危害分析和关键控制点（hazard analysis and critical control point，HACCP），失效模式影响分析（failure mode and effects analysis，FMEA），失效模式、效应与危害性分析（failure mode，effects and criticality analysis，FMECA）的风险管理方法，确定关键控制点，对失效后果危害性进行分析，确定风险优先指数并进行评估。结果：针对各使用环节可能发生的错误设置控制措施，确定胰岛素使用关键控制点为：防范处方错误、调剂错误、用药依从性错误。目前某院胰岛素药品使用失效后果的风险优先指数大多处于低风险或中等风险的等级。结论：胰岛素使用过程中应重点防范处方错误、调剂错误、用药依从性错误的发生。HACCP、FMEA、FMECA是适合医院药品风险管理的方法。药师参与是减少用药错误的重要保障。

Risk management of insulin and its analogues in the prevention of medication errors

OBJECTIVE To strengthen management of insulin and its analogues to ensure medication safety.METHODS By referring to HACCP, FMEA and FMECA, critical control points were identified and risk priority numbers were evaluated after criticality analysis.RESULTS Prescribing errors, dispensing errors and medication compliance errors were 3 critical control points identified after evaluating every possible errors in each links of insulin utilization. Most of risk priority numbers of failure mode in insulin utilization were in at low or moderate risk.CONCLUSION More attention should be paid on prevention of prescribing errors, dispensing errors, medication compliance errors in insulin utilization. HACCP, FMEA and FMECA are suitable risk management approaches in hospital. Pharmacists play important roles in reducing medication errors.