关键词: 给药错误；信息化；根本原因分析

Abstract: Objective: To apply Root Cause Analysis (RCA) to medication administration errors in an informatization context and to explore improvement strategies, providing guidance for reducing such errors. Methods: A retrospective analysis of 17 medication error incidents that occurred from January 2018 to May 2024 was conducted. The main causes were analyzed using a fishbone diagram, and the "5WHY" method was employed to delve into the root causes, and develop improvement strategies based on these causes. Results: By monitoring barcode scanning compliance, various types of scanning rates improved. Supervision of nurses' behavior, revision and detailing of medication administration processes, optimization of self-prepared medication coding procedures, and intelligent management of diluent expiration dates reduced the occurrence of medication errors. Conclusion: In an informatization context, managers need to continuously optimize and improve strategies based on the root causes of medication errors, leveraging the advantages of information technology to better assist nurses in administering medications and reduce the occurrence of medication errors.

Key words: medication errors; informatization; Root Cause Analysis