摘要
目的探讨整合性根本原因分析(RCA)在给药近似错误事件分析中的应用效果,为临床近似给药错误事件管理提供参考。方法采用非同期前后对照研究。回顾性分析2021年1—9月山东第一医科大学附属省立医院心内科发生的3例给药近似错误事件资料,应用整合性RCA找出近端原因,应用系统图、问题树分析确定根本原因,通过屏障分析制订改善对策,包括完善医院信息系统(HIS)安全屏障、更新心内科药物说明书数据库、规范护士处理审核医嘱制度屏障、目视化管理屏障等措施,并将整合性RCA改善对策应用于给药近似错误事件的管理。通过比较改善前(2021年1—9月)和改善后(2023年9月至2024年5月)给药错误不良事件发生例数、HIS药物医嘱错误率、药房发药拦截数量、医生HIS医嘱处理时间、医护人员药物知识考核合格率对改善效果进行评价。结果改善前心内科医护人员32名,男6名,女26名,年龄(31.03±4.29)岁。改善后医护人员30名,男6名,女24名,年龄(31.20±4.37)岁。实施整合性RCA改善后,给药错误不良事件发生例数由改善前的3例降为改善后的0例。HIS药物医嘱错误率由改善前的11.83%(11/93)降低至改善后的2.74%(2/73)。改善前前置审核系统无药房发药拦截功能,改善前申领药物信息6990条,发药拦截数量为0条;改善后申领药物信息7782条,发药拦截数量为78条,改善前后比较差异有统计学意义(χ^(2)=68.54,P<0.05)。改善后医生HIS医嘱处理时间包括入院、出院、术前、术后、检查用药、临时医嘱,分别为(1.14±0.41)、(1.37±0.30)、(0.43±0.11)、(0.51±0.11)、(0.40±0.10)、(0.51±0.14)min,均低于改善前的(4.07±0.70)、(3.69±0.60)、(1.44±0.24)、(2.10±0.45)、(1.41±0.28)、(1.44±0.29)min,差异均有统计学意义(t值为15.21~21.42,均P<0.05)。医护人员药物知识考核合格率由改善前的81.25%(26/32)提升到改善后的100.00%(30/30),差异有统计学意义(P<0.05)。结论应用整合性RCA对给药近似错误事件分析,有助于更全面地识别电子化医嘱给药工作流程中的系统缺陷,提升工作效率,保证医疗护理质量安全。
Objective To explore the application effect of integrated root cause analysis(RCA)in the analysis of approximate administration error events,and to provide reference for the management of clinical approximate administration error events.Methods A non-synchronous pre-and post-control study was conducted.The data of 3 cases of approximate error events of drug administration in the Department of Cardiology,Shandong Provincial Hospital Affiliated to Shandong First Medical University from January to September 2021 were retrospectively analyzed.The integrated RCA was used to find out the proximal causes,and the system diagram and problem tree analysis were used to determine the root causes.The improvement measures were formulated through barrier analysis,including improving the safety barrier of hospital information system(HIS),updating the database of drug instructions in the Department of Cardiology,standardizing the barrier of nurses′treatment and examination of medical orders,and visual management barrier.The integrated RCA improvement measures were applied to the management of approximate error events of drug administration.The improvement effect was evaluated by comparing the number of adverse events of medication errors before improvement(January to September 2021)and after improvement(September 2023 to May 2024),the error rate of HIS drug orders,the number of drug interceptions in pharmacies,the processing time of doctors′HIS orders,and the qualified rate of medical staff's drug knowledge assessment.Results There were 32 medical staff in the department of cardiology before improvement,including 6 males and 26 females,aged(31.03±4.29)years old.After improvement,30 medical staff,6 males and 24 females,aged(31.20±4.37)years old.After the implementation of integrated RCA improvement,the number of adverse events of medication errors decreased from 3 cases before improvement to 0 cases after improvement.The error rate of HIS drug orders decreased from 11.83%(11/93)before improvement to 2.74%(2/73)after improvement.Improve the pre-audit system without pharmacy drug delivery interception function,improve the pre-application drug information 6990,the number of drug interception was 0;after improvement,7782 pieces of drug information were claimed,and the number of drug interceptions was 78.The difference before and after improvement was statistically significant(χ^(2)=68.54,P<0.05).After the improvement,the doctor′s HIS doctor′s order processing time including admission,discharge,preoperative,postoperative,examination and medication,and temporary doctor′s order processing time were(1.14±0.41),(1.37±0.30),(0.43±0.11),(0.51±0.11),(0.40±0.10)and(0.51±0.14)min,respectively.They were lower than(4.07±0.70),(3.69±0.60),(1.44±0.24),(2.10±0.45),(1.41±0.28)and(1.44±0.29)min before improvement,and the differences were statistically significant(t values were 15.21-21.42,all P<0.05).The qualified rate of drug knowledge examination of medical staff increased from 81.25%(26/32)before improvement to 100.00%(30/30)after improvement,and the difference was statistically significant(P<0.05).Conclusions The application of integrated RCA to analyze the approximate error events of drug administration is helpful to identify the system defects in the workflow of electronic medical order administration more comprehensively,improve work efficiency and ensure the quality and safety of medical care.
作者
王爱霞
王迪
张晓曼
姜琦
付秀
王伟
Wang Aixia;Wang Di;Zhang Xiaoman;Jiang Qi;Fu Xiu;Wang Wei(Cardiology Department,Shandong Provincial Hospital Affiliated to Shandong First Medical University,Jinan 250021,China;Pharmacy Department,Shandong Provincial Hospital Affiliated to Shandong First Medical University,Jinan 250021,China;Information Network Center,Shandong Provincial Hospital Affiliated to Shandong First Medical University,Jinan 250021,China)
出处
《中国实用护理杂志》
2025年第18期1426-1434,共9页
Chinese Journal of Practical Nursing
基金
山东省医药卫生科技项目(202303010274)
山东第一医科大学附属省立医院2022年度教学改革与研究项目(SYJG-202203)。
关键词
给药近似错误
整合性
根本原因分析法
不良事件分析
Administration of the approximation error
Integration
Root cause analysis
Analysis of adverse events
作者简介
通信作者:王伟,Email:147078729@qq.com。
