对27例死亡病例现场调查发现的问题的思考

Consideration of On-the-spot Surveys of 27 Dead Cases Caused by Adverse Drug Reactions/Events

目的:探讨现场调查在药品不良反应监测工作中的作用与存在问题,为推动药品不良反应/事件调查、分析与评价提供借鉴。方法:回顾性分析江苏省药品不良反应监测中心2008年收到"不良反应结果"为"死亡"的《药品不良反应/事件报告表》及开展现场调查的情况。结果:报告涉及60岁以上老人最多;药品以抗感染药最多;剂型以粉针剂和注射剂为多;用药途径以静脉滴注最多;合并用药现象普遍;现场调查完成率44.44%。结论:调查工作的顺利开展需要多部门间的良好合作;应加强对药品购销及合理使用的管理。

Objective： To explore the effects and problems of on-the-spot surveys to provide reference for promoting the investigation, analysis and evaluation of adverse drug reactions/events. Method： By the retrospective case study, 27 ADR/ADE death reports and their corresponding on-the-spot surveys were analyzed in Jiangsu province in 2008. Result： The death occurred more in the elderly, the ADR drugs were more seen in the use of antibiotics, and ADRs occurred highly in the venous injection, and the the completion rate of the scene survey was 44.44%. Conclusion： The on-the-spot survey needs good cooperations from various departments, and the management of drugs should be strengthened.