目的：探讨确保小儿门诊输液安全、杜绝给药差错的有效管理方法。方法通过分析发生的给药差错，陕西省人民医院于2014年5月开始实施在收药处发号、输液时对号，以及输液、续液时与患儿家长双人查对制度。将实施前一年（2013年3月至2014年4月）115209人次接受静脉输液治疗的患儿作为对照组，实施后一年（2014年5月至2015年4月）132083人次患儿作为观察组，比较前后两年的给药不良事件、差错、投诉等发生情况及家长满意度和护士的评价进行统计比较，并进行统计分析。结果实施发号、对号与患儿家长双人查对制度后，收药缺陷、输液差错、换药差错、流程缺陷、纠纷投诉的发生率与实施前比较差异均有统计学意义（χ2值分别为16．311、8．284、14．905、14．076、4．808，均P＜0．05）。患儿家长满意度由实施前的75．67％提高至实施后的95．77％，差异有统计学意义（χ2＝25．998，P＜0．01）。护士评价在杜绝差错、加强健康教育、提高患儿对医护人员的信任、提高输液安全质量评价与实施前比较差异均有统计学意义（ t值分别为－4．077、－7．361、－6．940、－3．563，均 P＜0．05）。结论儿科门诊输液间静脉输液治疗中实施与患儿家长双人查对制度，能明显减少给药缺陷和投诉，杜绝差错，提高患儿家属的满意度。%Objective To find an effective management method for ensuring safe pediatric outpatient infusion and reducing medication errors.Methods The number of medication errors occurred before and after the implementation of the safety measures was compared.Since May 2014, the hospital implemented the following methods to secure outpatient infusion safety:a registration number was given to patients when drugs were given in infusion room and the number had to be double checked by patients’ parents and nurses before beginning infusion and changing drugs.The 115 209 pediatric patients receiving infusion in the year before the implementation of the method ( from March 2013 to April 2014) were selected in control group.The 132 083 pediatric patients receiving infusion in the year after the implementation of the method (from May 2014 to April 2015) were in observation group.The occurrences of medication errors and patient complaint, satisfaction of parents and evaluation of nurses were compared between two groups.Results The occurrences of drug delivery error, infusion error, drug changing error, process defect and patient complaint after implementation of the method were significantly different from those before the implementation (χ2 value was 16.311, 8.284, 14.905, 14.076 and 4.808, respectively, all P <0.05).The parent satisfaction rate increased from 75.67% before method implementation to 95.77% after implementation, and the difference had statistic significance (χ2 =25.998, P<0.01).Nurses evaluated that error prevention, health education, doctor-patient trust, and infusion safety were different (t value was -4.077, -7.361, -6.940 and -3.563, respectively, all P<0.05).Conclusion The implementation of double check by patients’ parents and nurses for the pediatric outpatient infusion can significantly reduce medication error and patient complaint and improve the patient’ s satisfaction rate.
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