对儿童抗瘤药物使用安全事件的根本原因分析
Elizangela Domiciano Garcia Barreto1,2, Valcieny Souza Sandes1,2, Gustavo Cattelan Nobre1
1Universidade Federal do Rio de Janeiro. Rio de Janeiro, Rio de Janeiro, Brazil.
Revista brasileira de enfermagem
|July 17, 2024
概括
分析儿科瘤学药物处理过程中的安全事件,揭示了关键因素,如中断和人员短缺. 根源原因分析 (RCA) 可以提高护理质量并减轻风险.
科学领域:
- 在瘤学瘤学.
- 制药科学 制药科学
- 患者安全 患者安全
背景情况:
- 儿科瘤学中的药物错误是一个重大问题.
- 了解对处方,制备和分发抗瘤药物的事件有贡献的因素,对于提高患者安全至关重要.
研究的目的:
- 识别和分析在儿科瘤学中抗瘤药物治疗过程中导致安全事故的因素.
- 通过事件分析,提高儿科药物护理的质量.
主要方法:
- 在2019-2020年期间进行了一项质量改进研究.
- 在科儿科药物护理中的事件被确定和分析.
- 一个多学科的小组进行了根源原因分析 (RCA),以确定导致因素.
主要成果:
- 2019年有7起事件被记录,其中57%与处方有关.
- 2020年,有34起事件被确定,其中65%与处方相关,29%与准备相关,6%与发行相关.
- 主要因素包括中断,缺乏电子警报,工作超负荷,培训不足和人员短缺.
结论:
- 有效的记录和事件的RCA可以显著提高儿科瘤治疗的质量.
- 绘制贡献因素的地图使管理人员能够制定有针对性的行动计划.
- 缓解药物处理过程中的风险对于患者安全至关重要.
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