22.高警示药品管理制度.pdf

高警示药品管理制度一 目的：规范高警示药品使用管理，确保药品使用安全。二 适用范围：本管理制度适用于院内使用与管理高警示药品的各科室。三 定义：1 高警示药品(High-alert medication)包括高危药品与易混淆药品。2 高危药品(High-risk medication)是指如果使用不当或使用错误，会对患者造成严重不良后果甚至死亡的药品，如胰岛素、肝素、化疗药物、高浓度电解质包括氯化钾（浓度 2mEq/mL）、氯化钠（浓度 0.9%）、硫酸镁（浓度50%）等。3 易混淆药品是指工作中容易混淆出错的药品,包括看似，听似、一品多规的药品。4 看似(Look-alike)、听似(Sound-alike)药品是指药物名称、外包装、标签、临床使用方面看似或听似的药品，如：异环磷酰胺针、环磷酰胺针、环磷腺苷针等。5 一品多规药品：某些日常工作中容易出现差错的同一通用名不同规格，或同一成分但不同剂型的药品。四 权责：药剂科负责高警示药品目录的及时更新及全院高警示药品储存与使用的检查监督，贮有高警示药品的各部门负责药品的具体管理。五 作业内容：1 高危药品管理1.1 高危药品目录：根据浙江省高危药品管理制度（试行稿）的要求，参考美国药物安全使用协会(ISMP)相关内容，结合我院实际情况，制高警示药品管理制度定高危药品目录，见附表1。1.2 高危药品的存放与标识：1.2.1 药品库房和各调剂部门的高危药品需专区存放，并标红底黑字标识1.2.2 除麻醉药品、第一类精神药品及抢救车药品外，各护理单元原则上不存放高危药品。如确需存放，应向药剂科申请，经医务科审查、药事管理与药物治疗学委员会批准备案，并严格按照高危药品管理，如专柜存放、红底黑字标识。1.2.3 发往病区拆除外包装的高危药品、高浓度电解质应在药品上贴相应标签。1.3 高危药品的处方：开具处方（医嘱）需要慎重，应保证处方适宜性，确保适应症、用法用量、给药途径、滴注速度等的正确性，避免处方环节的临床用药失误发生。使用计算机医嘱系统录入高危药品时，药品名称前标注 GW 以别于其他药品，提醒录入者此药为高危药品；电子处方及电子药品发放单上也显示红色GW，以示区别，提醒药品调剂、发放者严格核对。1.4 高危药品的调配：要实行双人复核，确保发放准确无误，避免调配环节的临床用药错误发生。1.5 高危药品的配置：须有双人核对。1.6 静脉用胰岛素、静脉用肝素、化疗药物、麻醉药品和第一类精神药品的给药应执行双核对制。1.7 医护人员需对使用高危药品的患者，根据药品风险因素和监测要点加强监测，一旦发现异常情况，立即与主诊医师沟通并及时处理。具体要求文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3文档编码:CZ9C9A8D5A9 HR2H4P10E6H5 ZO5V10B3P10E3高警示药品管理制度见附录 2 1.8 信息科负责高危药品医嘱标识模块的建立，药剂科负责高危药品目录日常维护。2 易混淆药品管理2.1 易混淆药品目录建立与维护：2.1.1 药品保管员验收新药或已有药品时，若发现有易混淆药品，应上报药品信息员，信息员及时把药品增加到易混淆药品目录（附录3）中，在药品信息中做相应的设置。并及时通知各调剂部门。2.1.2 药剂科各部门领入新药或已有药品时，若发现有易混淆药品，应及时与药品信息员联系，完善本部门药品目录，以防易混淆药品疏漏。2.2 防范措施：2.2.1 易混淆药品存放处贴上全院统一的警示标识，分开放置。2.2.2 外形相似药品制作外形相似药品对比图和目录，并进行张贴。2.2.3 读音听似药品医嘱录入时有提示。2.2.4在处方、医嘱调剂单上易混淆药品应在药品名称前加XS 字母区别。2.3 临床各科室：2.3.1 医生开立医嘱时须仔细，避免易混淆药品选择错误，用法、用量错误。2.3.2 护士做好自己部门的药品管理工作。给药时须仔细，避免易混淆药品有关的给药错误和迹近差错。2.4 信息科：信息科负责易混淆药品医嘱标识模块的建立；2.5 药剂科：药剂科负责具体品种维护。文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9高警示药品管理制度3 监督管理：医院建立全院高警示药品储存与使用的管理制度和流程，药剂科负责每月 1 次对全院使用与管理高警示药品的各科室进行检查，发现问题，督促整改。文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 HZ1Y8Z7L2R5 ZL6Q4S7G6F9文档编码:CJ10P10B3F9U8 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