CAJ | 학술논문

应用根原因分析法分析1例靶向药物给药错误事件的原因，提出整改方案。通过事件调查、直接原因分析，确认根原因为：无自备药物交接流程，配药流程不合理，实习生带教不规范，对护士工作流程与查对制度培训不够。针对原因制定改进措施：制定自备药物交接流程，制定自备药物使用规定，优化配药流程，规范输液贴信息管理，规范实习生管理，加强对护士的培训及检查，对患者进行安全教育，避免类似事件的发生，提高给药安全。
응용근원인분석법분석1례파향약물급약착오사건적원인，제출정개방안。통과사건조사、직접원인분석，학인근원인위：무자비약물교접류정，배약류정불합리，실습생대교불규범，대호사공작류정여사대제도배훈불구。침대원인제정개진조시：제정자비약물교접류정，제정자비약물사용규정，우화배약류정，규범수액첩신식관리，규범실습생관리，가강대호사적배훈급검사，대환자진행안전교육，피면유사사건적발생，제고급약안전。
Analyzed the causes of one targeted drug dosing error with root cause analysis and put forward improvement plans. Through investigating and analyzing the direct causes, root causes were identified as absence of autonomous medicine handover process, irrational dispensing flow, substandard practice guiding and insufficient training on nurses for their work flow and check system. Based on the above causes, improvement measures were made and safety education on patients were carried out so as to prevent the occurrence of these errors and improve medication safety.