128起给药错误分析

Analysis of 128 medication errors

目的:描述给药错误的分类、给患者造成的后果、造成给药错误的原因。方法:对128起给药错误事件进行回顾性分析。结果:护士给药错误占所有给药错误的69.6%,护士转录错误占16.4%。给药错误的分类中,剂量错误占34.5%,其次为药物错误,占19.4%。96.1%的给药错误未对患者造成伤害。造成给药错误的原因中,医护人员个人因素占67.9%,其中违反操作规则,疏忽、粗心,转录错误为主要原因;组织系统因素占17.7%,其中工作频繁被打断、注意力分散、安排没有经验的员工为主要原因。结论:管理者应鼓励医护人员主动上报所有的给药错误,对给药错误的资料进行分析,对组织系统因素进行改善。

Objective：To describe type,consequence of medication errors,and identify the contributory factors.Methods：Totally 128 medication errors were analyzed using retrospective study.Results：Among the 128 medication errors,69.6% occurred in medication administration,16.4% occurred in transcription.Wrong dose accounted for 34.5%,followed by wrong drug （19.4%）.96.1% medication errors did not cause patient harm.In terms of contributory factors,professional issues accounted for 67.9%,failure to follow procedures or protocol and performance deficit were the main causes; system issues accounted for 17.7%,frequent interruptions and distractions and assignment or placement of inexperienced personnel were the main causes.Conclusion：Managers should encourage medial staff to report medication errors,analyze them,and develop the strategies aiming at the system issues.