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目的:减少门诊药房调剂差错,确保用药安全。方法:对影响门诊药房调剂的各环节即采购、验收、储存、请领、上架、调剂、发放及相关风险因素(药库、门诊药房、门诊医师、网络系统因素)进行根因分析,有针对性地采取改进措施并落实,并对实施风险管理前(2013年6月1-30日)、后(2013年7月1-30日)门诊药房调剂(连续调剂60天7 000张门诊处方)的差错进行对比。结果与结论:制订并实施了包括落实相关制度、强化药品标识管理、加强培训及学习、优化调剂流程、改善窗口环境等改进措施;实施风险管理后内差事件发生件数降低,与实施前比较差异具有统计学意义(χ2=35.405,P<0.001),外差发生件数降为0。表明实施风险管理后相关人员风险意识显著加强,调剂差错数量明显减少,促进了用药安全。
Objective: To reduce errors in outpatient pharmacy adjustment and ensure medication safety. Methods: The root causes of purchasing, accepting, storing, receiving, shelving, adjusting, issuing and related risk factors (pharmacy, outpatient pharmacy, outpatient physician and network system factors) affecting outpatient pharmacy adjustment were analyzed. Take corrective measures and implement it in a timely manner, and adjust the outpatient pharmacies before the implementation of risk management (from 1 to 30 June 2013) and after (from July 1 to July 30, 2013) (the continuous adjustment of 7 days outpatient prescriptions for 60 days) The error is compared. RESULTS AND CONCLUSION: Measures were put in place and implemented, including the implementation of related systems, strengthening of drug labeling management, training and learning enhancement, optimizing the process of adjustment and improvement of the window environment. After the risk management, the number of internal incidents decreased and was different from before implementation With statistical significance (χ2 = 35.405, P <0.001), the number of occurrences of heterosis decreased to zero. It shows that the risk awareness of relevant personnel after the implementation of risk management is significantly strengthened, the number of adjustment errors is obviously reduced, and drug safety is promoted.