Kaiser模型在PIVAS肠外营养液风险管控中的应用OA

Objective To analyze the potential risk factors in the daily management of parenteral nutrition solution in pharmacy intravenous admixture services(PIVAS),and clarify the direction and focus of risk management.Methods The pharmacists and nurses in the hospital PIVAS were selected as the research subjects,and the questionnaire contents were determined through semi-structured interviews.The hazard vulnerability analysis(HVA)survey of parenteral nutrition solution was carried out in June 2022.Based on Kaiser model,the risk assessment was conducted,the risk value was calculated and the risk matrix was drawn to determine the high-risk events with high probability and high severity,and the corresponding strategies were formulated for intervention.The incidence of risk events of parenteral nutrition solution in PIVAS before and after intervention was compared.Results A total of 41 respondents were included,most of them were women(33 cases,80.49%),pharmaceutical technicians(40 cases,97.56%)and primary titles(27 cases,65.85%).The average working years in PIVAS was(4.26±3.28)years.The questionnaire included 44 risk events,including 10 in the environmental category,21 in the human category,6 in the technical category and 7 in the material category;a total of 41 questionnaires were distributed,and the effective recovery rate was 100%;among the top 10 events in risk value,7 were high-risk events with high possibility and high severity,which were in the following order:failure to identify medical orders(20.20%),failure to detect drug dispensing errors during verification(19.09%),wrong dispensing varieties(18.96%),non-standard disinfection operations(17.61%),non-compliance with aseptic techniques in preparation(16.73%),substandard cleanliness in functional areas(16.29%),and insufficient staff training(15.78%);after formulating corresponding strategies and carrying out intervention,the rate of irrational medical orders of parenteral nutrition solution decreased from 0.66‰ to 0.19‰,the error rate of dispensing decreased from 1.71‰ to 0.44‰,and the error rate of dispensing decreased from 1.45‰ to 0.63‰(P<0.05).Conclusion To develop the HVA analysis based on Kaiser model can provide scientific guidance for parenteral nutrition solution risk management in PIVAS,provide basis for formulating targeted strategies and organizing training effectively,and reduce the incidence for risk events of parenteral nutrition in PIVAS.