A quantitative analysis of error risk and risk prevention in Pharmacy Intravenous Admixture Services
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摘要:目的
总结分析静脉用药调配中心发生的差错, 探讨风险防范措施，以保障临床用药安全。
方法基于“瑞士奶酪模型”对2019—2020年安徽医科大学第一附属医院静脉用药调配中心各工作环节出现的差错进行回顾性分析，并提出相应防范改进措施。统计配置总袋数、差错袋数、差错频次、风险因素频次、差错总发生率、漏洞差错占比、漏洞系数、风险防范提升率等风险指标结果，比较改进前后静脉用药调配中心的差错发生情况。
结果改进后(2020年1—12月)的差错总发生率、漏洞差错占比分别为0.12‰、16.30%, 低于改进前(2019年1—12月)的0.16‰、31.30%, 差异有统计学意义(χ2=5.642、10.021, P=0.018、0.002)。改进后，漏洞系数由0.46降至0.19, 风险防范提升率为58.70%。
结论运用“瑞士奶酪模型”定义差错频次、漏洞差错占比、漏洞系数、风险防范提升率等风险量化指标，对静脉用药调配中心发生的差错及差错传导情况进行全面总结分析，制订并实施针对性改进措施，可以有效提升风险防范能力，减少差错发生，切实保障患者安全合理用药。
Abstract:ObjectiveTo summarize and analyze the errors occurred in the Pharmacy Intravenous Admixture Services, to explore measures of risk prevention so as to ensure the safety of clinical medication.
MethodsAccording to the "Swiss cheese model", the errors in each work link in the Pharmacy Intravenous Admixture Services of the First Affiliated Hospital of Anhui Medical University from 2019 to 2020 were retrospectively analyzed, and the corresponding prevention and improvement measures were proposed. The total number of allocated bags, the number of error bags, the frequency of errors, the frequency of risk factors, total incidence of error, the proportion of missed errors, the vulnerability coefficient, the promotion rate of risk prevention and other indicators were counted, and the occurrence of errors in the Pharmacy Intravenous Admixture Services were compared before and after improvement.
ResultsThe total error rate and missed error ratio after improvement (January to December 2020) were 0.12‰ and 16.30%, which were significantly lower than 0.16‰ and 31.30% before improvement (January to December 2019) (χ2=5.642, 10.021; P=0.018, 0.002). After improvement, the vulnerability coefficient decreased from 0.46 to 0.19, and the promotion rate of risk prevention was 58.70%.
Conclusion"Swiss cheese model" is used to define the risk quantitative indicators such as error frequency, proportion of vulnerability error, vulnerability coefficient, promotion rate of risk prevention, comprehensively summarize and analyze the errors and error transmission in the Pharmacy Intravenous Admixture Services, and formulate and implement targeted improvement measures, which can effectively improve the risk prevention ability, reduce occurrence of errors, and effectively ensure the safe and rational drug use for patients.
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表 1 改进前后差错发生情况
时期 总袋数 差错发生情况 风险防范提升率/% 差错袋数 差错总发生率/‰ 差错频次/次 漏洞差错占比/% 漏洞系数 改进前 978 368 158 0.16 230 31.30 0.46 — 改进后 936 610 113 0.12* 135 16.30* 0.19 58.70 与改进前比较, * P < 0.05。 
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