目的：减少静脉药物集中调配差错，提高输液配制质量，保证临床输液安全性与合理性。方法：首先运用个案追踪法逐一分析静脉用药调配中心（PIVAS）的各工作环节，找出可能造成调配差错的原因，进行风险控制；而后运用系统追踪法，剖析系统或流程内部潜藏的安全风险与质量裂痕，制订对策，持续改进并评价前后6个月的管理效果。结果：通过追踪方法学找出造成调配差错的关键环节及流程中存在的缺陷并改进相关工作模式、改善工作环境、制订并完善相关制度。通过系列措施的实施，调配差错由81袋减少到38袋，差错率由0.035％降低到0.011％（P＜0.01）。结论：运用追踪方法学寻找调配差错原因及环节，针对性制订相关措施并严格执行，可减少静脉药物调配差错，促进医疗用药安全。%OBJECTIVE:To reduce dispensing errors in Pharmacy intravenous admixture service(PIVAS),improve compound-ing quality of transfusion and guarantee the safety and rationality of clinic transfusion. METHODS:The case tracking method was applied to analyze each link of the work in PIVAS to find the reasons of configuration errors and control risk;and then the system tracking method was applied to analyze the hidden safety risk and the crack of quality from the inside of the system and work flow. Countermeasures and supporting continuous improvement were established to evaluate the effect of management before and after 6 months. RESULTS:Tracer methodology(TM)was adopted to find out the weakness in the key link and work flow of the cause of the configuration errors,the relative work pattern and work environment was improved,the relative system was formulated and completed,strength of rewards and punishment was increased. Through the implementation of the countermeasures,the number of dispensing errors was reduced from 81 to 38,and the error rate was reduced from 0.035% to 0.011%(P<0.01). CONCLU-SIONS:TM can be adopted in the key link and work flow of the cause of the configuration errors,aim at formulate and strictly carry out relative countermeasures to reduce errors in PIVAS,and promote the safety of drug use.
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