目的 探讨10％水合氯醛溶液的用药风险防范策略,提高儿童使用该药物的用药安全.方法 通过文献调研、临床安全用药监测网用药错误数据库、问卷调查(医师、护士、药师和患者)及实地考察收集整理10％水合氯醛溶液的失效模式或风险点,按照“HIS、医师处方、药师调配、护士给药及患者用药”不同环节进行分类,并采用失效模式与效应分析法(FMEA)进行风险优先级数评分,筛选得到各环节优先防范的风险点,分别制定防范策略且加以执行.结果 HIS系统无法拦截多科室重复开药;医生处方时因计算错误,导致处方药量错误;药师调配环节发错药(特别是多发);护士不知道水合氯醛是高警示药品;患者用药时因理解或操作错误,服用过量的水合氯醛,为各环节风险优先级数评分最高的风险点.在实施一系列防范措施后,我院未再发生严重水合氯醛用药错误事件.结论 对10％水合氯醛溶液建立切实可行的风险防范策略,可实现高警示药品全程规范化管理,提高用药安全.%Objective The medication errors prevention strategies for 10％ chloral hydrate solution were discussed in this artcle,so as to improve its use safety inpediatric patients.Methods Risk issues of 10％ chloral hydrate solution were collected by literature research,clinical drug safety monitoring network ME database,questionnaire (physician,nurse,pharmacist and patient) and fieldwork,and then classified to different aspects according to "HIS,prescription,pharmacistdispensing,the nurse and patient medication administration".Failure Mode and Effects Analysis (FMEA) was used to measure the Risk Priority Numbers (RPN),aiming to find out the priory risk issues and upon them to develop preventive strategies.Results HIS cannot prevent repeat prescriptions;doctors prescript with calculation errors;pharmacists dispensed wrong medicine (especially more administration);nurses do not know chloral hydrate is a high-alert drug;patients misuse medication because understanding or operator error.After a series of preventive strategies,no further chloral hydrate serious medication errors occurred in our hospital.Corclusion Practical prevention strategies can achieve10％ chloral hydrate solution standardized management and drug using safety.
展开▼
