Objective To explore and analyze the error accident of intravenous drug use control center, summarize the problems and develop solutions.Methods The relevant data of error accident in intravenous drug use control center at Heze City Hospital from May 2014 to September 2014 was retrospectively analyzed, the reasons and effective preventive measurement were received and summarized.Results In the hospital 43000 bags of infusion of intravenous drug use control center configuration, statistical errors were 345 times, accounting for 0.80% in total. It was consisted with the unreasonable doctor’s advice, 189 cases for 54.78%, and the reviewer’s wrong, including the 66 cases of drug mixing error accounting for 19.13%, 42 cases of large infusion mixing error accounting for 12.17%, and 17 cases of drug batch confusion accounting for 4.93%. It was also made by the infusion configuration errors, including 14 cases of dispensing improper operation accounting for 4.06%, 12 cases of inaccurate dose accounting for 3.48%, and 5 cases of improper parenteral nutrition bag order accounting for 1.45%.Conclusion The common errors of the intravenous drug use control center include the unreasonable doctor’s advice, the reviewer’s wrong, and infusion dispensing error, etc. In order to the realize safe and efficient intravenous drug configuration in the management of intravenous drug use control center, we should better discover the existing problems and develop effective solutions.%目的：探究与分析静脉用药调配中心发生的差错事故，总结其中存在的问题并制定解决措施。方法回顾性分析菏泽市立医院静脉用药调配中心在2014年5月～2014年9月发生的差错事故的相关资料，并总结其中原因，制定有效防范措施。结果在本院静脉用药调配中心配置的43000袋输液中，统计中出现差错共345次，发生率为0.80%。其中医师医嘱不合理189份，占54.78%；审核人员出现差错：药物调配错误66份，占19.13%，大输液调配错误42份，占12.17%，药物批次混淆17份，占4.93%；输液配置差错：配药操作不当14份，占4.06%，药物剂量不准确12份，占3.48%，肠外营养袋顺序不当5份，占1.45%。结论静脉用药调配中心常见的差错包括医师医嘱不合理，审核人员出现差错、输液配制差错等，对静脉用药调配中心的管理中存在的问题做到及时发现，以制定有效的解决措施，从而实现安全高效的静脉药物配置。
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