摘要
目的:探讨瑞士奶酪模型根因分析法在解放军总医院第五医学中心(以下简称"我院")门诊药房处方调剂管理中的应用效果。方法:2017年2月至2018年1月、2018年2月至2019年1月我院门诊药房分别采取常规安全管理模式、基于瑞士奶酪模型根因分析法的安全管理模式,调取上述两个阶段我院门诊药房发药处方460 890、504 589张,统计处方调剂差错事件,比较两种管理模式下的处方调剂差错发生率。结果:应用瑞士奶酪模型根因分析法后,我院门诊药房处方调剂差错率由常规安全管理模式下的0.058 58‰(27例次)明显降至0.021 80‰(11例次),差异有统计学意义(P<0.05)。结论:应用瑞士奶酪模型根因分析法指导处方调剂,能够有效降低差错率,拓宽管理者处理调剂差错的思维方式,有利于进一步加强药房的安全管理工作。
OBJECTIVE:To probe into the application effect of Swiss Cheese Model on prescription dispensing management in outpatient pharmacy in the Fifth Medical Center of PLA General Hospital (hereinafter referred to as “our hospital”).METHODS:Conventional safety management model and Swiss Cheese Model based root cause analysis of safety management model were respectively adopted during Feb.2017 to Jan.2018 and Feb.2018 to Jan.2019 in the outpatient pharmacy in our hospital,460 890 and 504 589 prescriptions in the above two stages were collected,error events were statistically adjusted to compare the incidences of prescription dispensing errors in the two management modes.RESULTS:After the application of Swiss Cheese Model based root cause analysis,the error rate of prescription dispensing had been decreased from 0.058 58‰(27 case-times) at conventional safety management model to 0.021 80‰(11 case-times),with statistically significant difference ( P <0.05).CONCLUSIONS:The application of Swiss Cheese Model based root cause analysis in prescription dispensing can effectively reduce error rate,broaden the way that administrators handle dispensing errors,which will help to further strengthen the safety management of pharmacy.
作者
于珊珊
张静
杜凤霞
王雪洁
蔡华丹
YU Shanshan;ZHANG Jing;DU Fengxia;WANG Xuejie;CAI Huadan(Dept.of Pharmacy,the Fifth Medical Center of PLA General Hospital,Beijing 100039,China)
出处
《中国医院用药评价与分析》
2019年第5期518-520,共3页
Evaluation and Analysis of Drug-use in Hospitals of China
基金
国家重点研发计划(No.2018YFC1704504)
关键词
瑞士奶酪模型根因分析法
调剂差错
门诊药房
Swiss Cheese Model based root cause analysis
Dispensing error
Outpatient pharmacy
