基于等级医院评审标准规范管理科室备用药品的实践(1)
[摘要] 目的 结合三级综合医院评审标准，规范科室备用药品管理。 方法 药事管理委员会于2015年3～12月运用3个周期PDCA循环管理方法对湖北省十堰市太和医院83个科室备用药品种类、分类、标识、贮存、使用、记录和领取进行质量持续改进。 结果 统一了全院急救药品的品种、基数和定位贮存，全院备用药品种类减少了54.63%；贮存数量显著减少，其中注射剂减少了65.42%；医务人员每次检查备用药品耗时缩短了63.28%；在第3周期PDCA检查中达到“备用药品管理质量合格率100%”的管理目标；在等级医院评审中受到专家高度赞扬。 结论 在等级医院评审安全理念指导下应用PDCA循环法，规范管理科室备用药品，提升了管理效能，保障备用药品使用安全性与及时性，降低了医院的成本，值得在临床实践工作中推荐。
[关键词] 等级医院评审标准；安全管理；备用药品
[中图分类号] R95 [文献标识码] A [文章编号] 1673-7210(2017)06(a)-0150-04
The practice of standardizing the management of standby drugs based on the hospital accreditation standards
LAN Hong1 CHEN Hongmei2
1.Department of Pharmacy， Shiyan Taihe Hospital Affiliated Hospital of Hubei University of Medicine， Hubei Province， Shiyan 442000， China； 2.Center for Mental Health Services， Shiyan Taihe Hospital Affiliated Hospital of Hubei University of Medicine， Hubei Province， Shiyan 442000， China
[Abstract] Objective To standardize the management of standby drugs based on the accreditation standards for class Ⅲ comprehensive hospital. Methods Three rounds of PDCA cycle management was applied to constantly improve drug classification， identification， storage， usage， record and claim of standby drugs among 83 departments of Shiyan Taihe Hospital under the instruction of the Pharmaceutical Affairs Board from March to December in 2015. Results The types， amounts and storage positions of the first-aid medicine were unified. The types was decreased by 54.63%； the storage was significantly reduced， among which the injection was reduced by 65.42%； and the inspection time of standby drugs by the medical staffs was reduced by 63.28%. During the third round of PDCA evaluation， the eligible rate of standby drugs was 100%， which was highly praised by the evaluation experts in the hospital accreditation. Conclusion It has been proved that by applying PDCA cycle management under the safety guidance of hospital accreditation can help to improve the management efficiency and guarantee the safety and speediness of standby drugs， reduce the management cost of hospital. Therefore， in clinical practice PDCA cycle management is highly recommended.
[Key words] Accreditation standards for hospital； Safety management； Standby drugs
湖北省十堰市太和醫院(以下简称“我院”)是一所国家综合性三级甲等医院，编制病床3260张，医院设有68个临床科室和15个医技科室。医院根据科室需要，常为科室备有一定数目的备用药品，以便解决患者及时临时用药问题。各科室负责备用药品的领取、使用和管理，药学部定期督查。药学部在督查中发现各科室备用药品管理有安全隐患。患者用药安全不仅是国家卫生和计划生育委员会十大安全目标，也是等级医院评审重要内容。我院于2015年3月按照《三级综合医院评审细则(2011版)》[1]，运用PDCA(计划、实施、检查、行动)循环管理[2]方法对全院83个科室备用药品管理进行持续质量改进，通过3个周期的PDCA循环，备用药品质量管理合格率达到100%。特别是在2015年11月等级医院评审中，专家对我院备用精神药品进行追踪检查后，给予了高度赞扬。现将我院备用药品管理报道如下：, http://www.100md.com(兰鸿 陈鸿梅)
[关键词] 等级医院评审标准；安全管理；备用药品
[中图分类号] R95 [文献标识码] A [文章编号] 1673-7210(2017)06(a)-0150-04
The practice of standardizing the management of standby drugs based on the hospital accreditation standards
LAN Hong1 CHEN Hongmei2
1.Department of Pharmacy， Shiyan Taihe Hospital Affiliated Hospital of Hubei University of Medicine， Hubei Province， Shiyan 442000， China； 2.Center for Mental Health Services， Shiyan Taihe Hospital Affiliated Hospital of Hubei University of Medicine， Hubei Province， Shiyan 442000， China
[Abstract] Objective To standardize the management of standby drugs based on the accreditation standards for class Ⅲ comprehensive hospital. Methods Three rounds of PDCA cycle management was applied to constantly improve drug classification， identification， storage， usage， record and claim of standby drugs among 83 departments of Shiyan Taihe Hospital under the instruction of the Pharmaceutical Affairs Board from March to December in 2015. Results The types， amounts and storage positions of the first-aid medicine were unified. The types was decreased by 54.63%； the storage was significantly reduced， among which the injection was reduced by 65.42%； and the inspection time of standby drugs by the medical staffs was reduced by 63.28%. During the third round of PDCA evaluation， the eligible rate of standby drugs was 100%， which was highly praised by the evaluation experts in the hospital accreditation. Conclusion It has been proved that by applying PDCA cycle management under the safety guidance of hospital accreditation can help to improve the management efficiency and guarantee the safety and speediness of standby drugs， reduce the management cost of hospital. Therefore， in clinical practice PDCA cycle management is highly recommended.
[Key words] Accreditation standards for hospital； Safety management； Standby drugs
湖北省十堰市太和醫院(以下简称“我院”)是一所国家综合性三级甲等医院，编制病床3260张，医院设有68个临床科室和15个医技科室。医院根据科室需要，常为科室备有一定数目的备用药品，以便解决患者及时临时用药问题。各科室负责备用药品的领取、使用和管理，药学部定期督查。药学部在督查中发现各科室备用药品管理有安全隐患。患者用药安全不仅是国家卫生和计划生育委员会十大安全目标，也是等级医院评审重要内容。我院于2015年3月按照《三级综合医院评审细则(2011版)》[1]，运用PDCA(计划、实施、检查、行动)循环管理[2]方法对全院83个科室备用药品管理进行持续质量改进，通过3个周期的PDCA循环，备用药品质量管理合格率达到100%。特别是在2015年11月等级医院评审中，专家对我院备用精神药品进行追踪检查后，给予了高度赞扬。现将我院备用药品管理报道如下：, http://www.100md.com(兰鸿 陈鸿梅)