181例给药近似错误的分析与对策

目的找出给药近似错误的影响因素,从根本上降低给药近似错误的发生率。方法对某三级医院给药近似错误的181例案例进行回顾性分析。结果给药近似错误发生率在调查期内逐年下降;药物错误、剂量错误在给药近似错误中的比例占60％以上;药物准备阶段发生近似错误的比例占60％以上;90％以上给药近似错误发生在白天：职称、工作年限和系统设备对降低给药近似错误有重要影响;不遵守工作流程、违反操作规程、因干扰工作连续性中断、沟通缺乏、粗心疏忽、记忆错误、药品相似性、信息系统信号差等因素是造成给药近似错误的主要原因。结论规范给药管理制度,将给药管理视为整体,实行全员的“Five Rights”管理。

In 181 cases with administration of approximate analysis and Countermeasures of errors

Objective To find the approximate error factors influence of dosing, fundamentally reduce the administration of approximate error. Methods According to the three level of hospital administration approximation error of 181 cases were retrospectively analyzed. Results The following factors were caused drug similar mistakes.Administration of the approximation error incidence decreased year by year during the investigation. Medication errors and errors in the approximation, error dose administered in the proportion accounted for more than 60%. More than 90% administration of the approximation error occurs during the day. The title, length of service and equipment have important effects on reducing drug approximation error, do not comply with the work flow, violating the operating rules, because of interference interrupts the continuity, the lack of communication, carelessness, memory errors, drug similarity, difference signal information system. Conclusion Specification for dug management system, the administration management as a whole, the full implementation of the ＂Five Rights＂ management.