中国药房2017，Vol.28Issue(34)：4834-4838,5.DOI:10.6039/j.issn.1001-0408.2017.34.21
应用HFMEA法促进肝素钠注射液在儿童用药中的安全管理
Promoting the Safety Management of Heparin Sodium Injection Used for Children by HFMEA Method
摘要
Abstract
OBJECTIVE:To promote the safe use of Heparin sodium injection for children. METHODS:According to litera-ture retrieve,questionnaire survey and field investigation,Health care failure mode and effect analysis method(HFMEA)was ad-opted to search for the failure modes of Heparin sodium injection for children,and preventive strategies were established and imple-mented based on these failure modes. Its effects were evaluated by comparing the error rate and risk priority number rating (RPN value)before and after the implementation. RESULTS:Totally 5 risk points of Heparin sodium injection requiring immediate inter-vention were obtained from RPN value,including wrong dose of Heparin sodium injection in prescribing,pharmacists'unclearness for the calculation method of the dose of Heparin sodium injection in dispensing,and nurses'no performing of double check sys-tem before infusion in administration,etc. After implementing related countermeasures,related error of Heparin sodium injection was decreased from 8 cases to 1 case,and error rate was declined from 3.76% to 0.51%(P<0.01). The RPN values of 5 failure modes were decreased from 112.08,91.56,115.78,94.52,99.23 to 28.02,23.91,27.71,23.63,20.55,respectively. CONCLU-SIONS:HFMEA can prospectively conduct systematical analysis for Heparin sodium injection for children. Implementing related countermeasures based on the current situation of our hospital can reduce the related error of Heparin sodium injection and promote the medication safety of children.关键词
肝素钠注射液/儿童患者/医疗失效模式与效果分析/用药安全Key words
Heparin sodium injection/Children patients/Health care failure mode and effect analysis/Medication safety分类
医药卫生引用本文复制引用
赵杰,张冠东,薛智民,杨钰,高燕飞,韩燕,赵瑞玲..应用HFMEA法促进肝素钠注射液在儿童用药中的安全管理[J].中国药房,2017,28(34):4834-4838,5.基金项目
2016年国家卫生和计划生育委员会药政司委托研究课题(No.药政〔2016〕61号) （No.药政〔2016〕61号）
