目的 探討失效模式與效應(yīng)分析（failure mode and effect analysis，F(xiàn)MEA）在住院藥房藥品調(diào)劑流程風(fēng)險(xiǎn)管理中的應(yīng)用效果，提高藥品調(diào)劑質(zhì)量。方法 對(duì)天津醫(yī)科大學(xué)腫瘤醫(yī)院住院藥房口服藥物調(diào)劑流程中各個(gè)環(huán)節(jié)進(jìn)行FMEA，計(jì)算風(fēng)險(xiǎn)優(yōu)先指數(shù)（risk priority number，RPN）。選出高風(fēng)險(xiǎn)等級(jí)的失效模式和中等風(fēng)險(xiǎn)等級(jí)中S≥4的失效模式，整理分析其失效原因，制定并實(shí)施改進(jìn)措施。比較實(shí)施FMEA方法前后失效模式變化情況，分析改進(jìn)效果。結(jié)果 住院藥房藥品調(diào)劑流程中共找出13個(gè)失效模式，其中高風(fēng)險(xiǎn)失效模式4項(xiàng)，極高風(fēng)險(xiǎn)失效模式2項(xiàng)。通過(guò)規(guī)范藥物醫(yī)囑流程、優(yōu)化HIS信息系統(tǒng)與擺片機(jī)對(duì)接執(zhí)行程序、修訂完善制度以及對(duì)藥師、護(hù)士進(jìn)行培訓(xùn)等方面干預(yù)，13項(xiàng)失效模式RPN均值由38降至15，降幅為60.53%。其中4項(xiàng)高等風(fēng)險(xiǎn)失效模式經(jīng)改進(jìn)后風(fēng)險(xiǎn)明顯降低，且差異有統(tǒng)計(jì)學(xué)意義（P＜0.05）。結(jié)論 將FMEA應(yīng)用于住院藥房藥品調(diào)劑流程風(fēng)險(xiǎn)管理，能夠有效降低拆藥過(guò)程藥品損失、機(jī)器誤差、HIS系統(tǒng)與擺片機(jī)信息對(duì)接失誤和取藥次數(shù)多、等候時(shí)間長(zhǎng)等問(wèn)題，提高藥品調(diào)配的及時(shí)性和準(zhǔn)確性，更好地服務(wù)于住院患者。

Objective To explore the application effect of failure mode and effect analysis (FMEA) in the risk management of drug dispensing process in inpatient pharmacy, and improve the quality of drug dispensing. Methods FMEA was performed on each link of oral drug dispensing process in inpatient pharmacy of Tianjin Medical University Cancer Hospital, and risk priority number (RPN) was calculated. The failure mode of high risk level and the failure mode of S ≥ 4 in medium risk level are selected, the failure causes are analyzed, and the improvement measures are formulated and implemented. The change of failure mode before and after the implementation of FMEA method was compared, and the improvement effect was analyzed. Results A total of 13 failure modes were found in the drug dispensing process of inpatient pharmacy, including 4 high-risk failure modes and 2 extremely high-risk failure modes. By regulating the process of drug doctor's advice, optimizing the implementation procedure of HIS information system and tablet dispensing machine, revising and improving the system, and training pharmacists and nurses, the mean RPN of 13 failure modes decreased from 38 to 15, with a decrease of 60.53%. The risk of four high risk failure modes was significantly reduced after improvement, and the difference was statistically significant (P < 0.05). Conclusion The application of FMEA in the risk management of drug dispensing process in inpatient pharmacy can effectively reduce the problems of drug loss, machine error, information docking error between HIS system and tablet machine, more drug taking times and long waiting time in the process of drug disassembly, improve the timeliness and accuracy of drug dispensing, and better serve the hospitalized patients.

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