叶美燕 周月琴 董灿红等

    [摘要] 应用根因分析法分析一起药患纠纷事件的原因。通过事件描述、事件调查、近端原因分析、确定根本原因、制订改进方法，认为发生药患纠纷的根本原因是风险管理理念不足，接药流程、摆药流程、配药流程不够合理，人力资源不足，各班工作职责不够明确，实习生的带教管理不规范。转变药患纠纷事件的风险管理理念、优化给药流程、重视给药环节的细节管理、增加人力资源配置、改变排班模式、完善新护士和实习护士的带教管理，以利于避免类似事件的发生，降低药患纠纷。

    [关键词] 药患纠纷；住院患者；根因分析法

    [中图分类号] R47 [文献标识码] A [文章编号] 1673-7210(2015)08(c)-0160-03

    [Abstract] Root cause analysis is applicated of the reason of medication disputes. By analyzing the root cause of medication disputes and improving on methods through the event description， the investigation as well as the proximate cause， it is observed that the root cause of medication disputes is the lack of risk management concept， unreasonable management of handling， displaying and dispensing medicine process， the lack of human resources， unclear assignments of responsibilities as well as non-standard intern training management. In order to avoid the occurrence of similar incidents and reduce medication disputes， it is necessary to change the risk management concept， optimize the dispensing process， emphasize on detail management of handling medicines ......