Application of Tracer Methodology in Reducing Dispensing Errors in PIVAS / 中国药房

ABSTRACT

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-SIONSTM 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.