35例严重药品不良反应致死亡的不合理用药分析

Analysis of Irrational Use of Drugs from 35 Death Cases in Adverse Drug Reaction Report

目的对广东省2009年严重药品不良反应致死亡报告中不合理用药情况进行分析,为进一步规范临床合理用药提供参考。方法使用广东省药品不良反应信息网络管理平台,筛选广东省2009年所有严重药品不良反应致死亡报告,参考药品说明书等对报告中不合理用药情况进行分析。结果 35份死亡报告表中,出现不合理用药12份,占死亡报告数的34.29%。乡、镇卫生院报告表出现不合理用药占其报告数的38.46%;县、区级医院报告表出现不合理用药占其报告数的35.71%;市级及以上医院报告表出现不合理用药占其报告数的25%。不合理用药表现涉及用药过量、理化配伍禁忌、溶媒选择不合理、超适应证使用、药物选用不当和重复用药等六个方面。结论各级医院都存在临床上不合理用药现象,基层医院不合理用药情况较严重。因此,要加强临床医生特别是基层医生合理用药的培训和指导。

Objective In order to explore and solve the problems of the irrational use of drugs,this study tried to analysis the dead cases from aduerse drug reaction（ADR） report database of Guangdong in 2009.Methods Screen the ADR report database of Guangdong in 2009 by Guangdong ADR monitoring system,select all of the death cases,abandon the deficient ones,then analysis the problems and frequencies of the irrational use of drugs.Results 25.71%（12/35） death cases were associated with irrational use of drugs.The frequencies of drug abuse are 25%,35.71% and 38.46% in municipal hospitals,county hospitals and township hospitals respectively.Furthermore,six dead cases may be blamed for inappropriate rescue,while five happened in township hospitals.The six concerns of irrational use of drugs were overdose,incompatibility,solvent selection error,beyond indications,drug selection error and Repeat medication.Conclusion Irrational use of drugs was common,especially in elementary hospital.The training and education of rational use of drugs for the staff of elementary hospital should be strengthened.