頁籤選單縮合
題名 | 運用根本原因分析提升用藥安全案例分享=Using Root Cause Analysis to Increase Patient Safety |
---|---|
作者 | 張美琪; 張秀玲; 吳宜珮; 蔡斌智; 林梅芳; Chang, Mei-chi; Chang, Hsiu-ling; Wu, Yi-pei; Tsai, Pin-chin; Lin, Mei-fang; |
期刊 | 藥學雜誌 |
出版日期 | 20100600 |
卷期 | 26:2=103 2010.06[民99.06] |
頁次 | 頁74-81 |
分類號 | 419.39 |
語文 | chi |
關鍵詞 | 根本原因分析; 給藥疏失; 病人安全; Root cause analysis; Medication error; Patient safety; |
中文摘要 | 本案件是利用根本原因分析方法( RCA: root cause analysis)進行回溯性分析並進一步謀求改善的對策,先以時間序列描述事件發生的過程,確認問題為『發藥藥師未確實覆核病患身份導致給錯病人藥物事件,且其中一病患已將降血糖的藥物誤服用一次,所幸及時發現經追蹤並未出現低血糖的症狀』。再利用因果圖及魚骨圖中找出近端原因為門診作業規範中對核對、發藥及領藥流程細節訂定不夠慎密、新進藥師對發藥流程不熟悉、個人疏忽、病患未依領藥動線移動等四項。再從近端原因中確認根本原因為缺乏雙重覆核辨識病人的標準作業流程,進一步利用屏障分析找出可行的對策以制立標準化的核對、發藥流程作業規範、加強用藥安全宣導、衛教病患藥袋資訊及加強領藥動線、海報及告示牌以提示病患正確領藥流程及動線、加強人員訓練與落實標準作業流程。經執行相關改善措施後,病人辨識錯誤的用藥疏失異常事件通報件數,從改善前一年發生數次減少到改善後已未再發生。 |
英文摘要 | This case study used the method of root cause analysis(RCA)to do the retrospective analysis and then search for policies for improving medication errors. First of all, we used a tabular timeline to describe the process of the events and identify the problem as the case that the pharmacist did not double-check accuracy of the patient identification and administered the right drug to the wrong patient. One of the patients had by mistake, taken the medicine of antidiabetic agents after one meal. Fortunately, it was found in time, and the symptom of hypoglycemia did not appear. Second, a why tree analysis and fishbone was used to find out four proximate causes. One is that the revised details for the procedures of double-checking, administrating the drug, and receiving medicine are not careful and completed enough; another is that a novice pharmacist does not know very well the administrating procedures, a third one is individual negligence; the last is that patients do not receive medicine according to the receiving line. Third, from the proximate causes, we confirmed the root cause was in lacking of the standardized process guideline for double-checking patients before administrating the drug. Fourth, a reactive barrier analysis was further used to discover feasible policies, which are double-checking administrating drug, enhancing the promotion of safety in taking medicine, educating patients about medicine bag information and the moving line of receiving medicine, setting up the poster and the bulletin sign, presenting patients with correct receiving medicine procedures and the moving line, making standardized procedures and training pharmacists in double-checking accuracy of patients. One year after enforcement of relevant improvement measures, the result shows that the occurrence of inadequate patient identification decreased from several times at the improving stage to none after the improvement. |
本系統之摘要資訊系依該期刊論文摘要之資訊為主。