应用HFMEA降低PIVAS用药错误发生率

目的 制定防范错误的相关策略，降低医院静脉用药集中调配中心（pharmacy intravenous admixture services，PIVAS）用药错误发生率。方法 利用医疗失效模式与效果分析法（healthcare failure mode and effect analysis，HFMEA），分析山西省儿童医院PIVAS工作流程中的失效模式并评估其风险，提出针对性的控制方案，再通过比较HFMEA实施前、后差错率和风险优先级数值评分评价实施效果。结果 HFMEA实施后，笔者所在医院PIVAS各环节错误发生率明显降低（P<0.01）。结论 采用HFMEA对PIVAS工作流程各环节进行风险防范管理，可有效减少工作中的用药错误，促进儿童用药安全。

Reducing Rate of Medication Errors in PIVAS by HFMEA

OBJECTIVE To reduce the medication errors of pharmacy intravenous admixture services(PIVAS) medication errors in hospital by developing the strategies. METHODS The healthcare failure mode and effect analysis(HFMEA) method was used to analyze the failure mode of workflow and assess their risks in PIVAS of Children''s Hosptial of Shanxi Province, and the reasonable control scheme was proposed. The implementation effect was evaluated by comparing the rate of medication errors and the value of risk priority number before and after the implement of HFMEA. RESULTS After the implement of HFMEA, the incidence of errors in PIVAS of the author''s hospital was decreased significantly(P<0.01). CONCLUSION HFMEA is used to prevent and manage risks in all aspects of PIVAS workflow, which can effectively reduce the medication errors in work and promote the safety of children''s medication.