根因分析法在提高科室备用药品质量管理中的应用

摘要:目的　分析根因分析法在科室备用药品质量管理中的应用效果，以提高用药安全与合理水平。方法　选取2014年3月-2014年6月调查医院发生的备用药品质量管理问题56起，应用根因分析法寻找质量管理问题的近端原因与根本原因，并制定改善策略与改进措施。结果　55起备用药品质量管理问题的近端原因有人员因素（护士、医师与药师）、沟通因素与环境因素，根本原因有备用药品管理机制不健全、强化培训不足，沟通渠道不通畅与质量管理流程不明确；根因分析法实施后，2014年第三季度的备用药品质量管理问题由2015年第一季度的55起降至8起（降幅85.45%），数量误差发生次数由25起降至5起（降幅80.00%），同种药品不同剂型混放发生次数由20起降至3起（降幅85.00%）。结论　科室备用药品质量管理中应用根因分析法，可有效降低不良事件的发生风险。

Application of root cause analysis method in improving department standby drug quality management

Abstract: Objective To analyze the application effect of root cause analysis method in improving department standby drug quality, and to enhance the level of medication safety. Methods Data (56 cases) were selected from the management issues of standby drug quality occurring in our hospital from March 2014 to June 2014. We investigated the proximate causes and root causes of quality management issues based on the root analysis method, and then established the improving strategies and measures. Results the proximate causes of 55 drug quality management issues included human factors (nurses, physicians and pharmacists), communication factors and environmental factors, while the root causes involved imperfect management system of standby drugs, which were lack of intensive training, smoothly communicative channels and ambiguous management processes. After the application of the root cause analysis method, the management issues of standby drug quality had decreased from 55 cases to 8 cases (degree of reduction 85.45%). The occurrences of quantitative error had also reduced from 25 to 5 (degree of reduction 80.00%). Meanwhile, the frequencies of the same drug in different dosage had declined from 20 to 3 (reduction 85.00%). Conclusion The root cause analysis method should be applied at department standby drug quality management, which can drop down the occurrences of adverse events.