| 摘要: |
| 目的:探讨医疗失效模式和效应分析(FMEA)结合社会技术概率风险评估(ST-PRA)在降低病区药房用药错误(ME) 中
的应用效果。方法:选取我院2022 年2-7 月调剂药品的条目数和出现的ME 的数量,作为基线水平。在此基础上采用医疗
FMEA 结合ST-PRA 进行药品管理,再次统计干预后2023 年2-7 月药品条目数量和ME。通过统计学方法比较风险优先指数
(RPN)及各项ME 发生情况。结果:用药差错数从338 下降至266,错误率从0. 096%下降至0. 059%,差异有统计学意义( P<
0. 05);RPN 从2 728. 4 下降至1 228. 0,差异有统计学意义(P<0. 05);其他各项用药差错对比皆有下降。结论:医疗FMEA 结合
ST-PRA 有助于降低病区药房的RPN,减少其给药错误率,降低潜在的用药风险,提高病区药房工作质量。 |
| 关键词: 用药错误 失效模式和效应分析 社会技术概率风险评估 |
| DOI：10.13407/j.cnki.jpp.1672-108X.2024.12.005 |
|
| 基金项目: |
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| Application of Medical Failure Mode and Effect Analysis Combined with Sociotechnical Probabilistic Risk Assessment in Reducing Medication Errors in Ward Pharmacy |
| Zhang Hao, Wang Xiaochuan, Guan Weiwei, Zhao Genghao, Wei Jinghai, Zhao Yiming |
| (Beijing Children’s Hospital,Capital Medical University, Beijing 100045, China) |
| Abstract: |
| Objective: To explore the application effects of failure mode and effect analysis (FMEA) combined with social technical
probabilistic risk assessment (ST-PRA) in reducing medication errors (ME) in ward pharmacy. Methods: The number of drugs and
ME in our hospital from Feb. to Jul. 2022 were extracted as the baseline data. On this basis, medical FMEA combined with ST-PRA
was used for drug management, and the number of drugs and ME from Feb. to Jul. 2023 after intervention were counted. The risk
priority number (RPN) and the occurrence of ME were compared statistically. Results: The number of ME decreased from 338 to 266,
and the error rate decreased from 0.096% to 0.059%, with statistically significant difference (P<0.05). The RPN decreased from 2,728.4 to
1,228. 0, with statistically significant difference (P<0. 05). There was a decrease in the comparison of other ME. Conclusion: Medical
FMEA combined with ST-PRA can help to reduce the RPN of ward pharmacy, decrease the rate of ME and potential medication risks,
and improve the working quality of ward pharmacy. |
| Key words: medication errors failure mode and effect analysis social technical probabilistic risk assessment |
