用药差错和潜在差错报告及干预系统的建立和评价

The Establish and Evaluate of Reporting,Surveillance and Intervention System of Medication Error and Potential Error in Hospital

目的:探讨建立用药差错和潜在差错的报告及干预系统,促进患儿用药安全。方法:选取2012年5-8月为用药差错及潜在差错基础报告期,2012年9-12月为分析干预期,研究对象为住院患儿。比较两个时期用药差错及潜在差错发生率的差异、差错类型的变化及上报人群组成的情况,从而对用药差错及潜在差错的干预效果进行评价。结果:2012年5-8月用药差错及潜在差错发生率分别为1.35%和0.55%,9-12月用药差错及潜在差错发生率分别为0.16%和5.20%,用药差错发生率明显下降(P<0.01),而潜在差错发生率升高(P<0.01);从差错类型来看,5-8月用药差错主要以给药时间错误为主,9-12月则以给药剂量错误为主;报告人群在干预前后均主要以药师为主。结论:通过建立完善的用药差错报告及干预系统,可明显减少用药差错的发生率。

Objective： To investigate the establish and evaluate of reporting, surveillance and intervention system of medication error and potential error in hospital, in order to improve the medication safety. Methods： The baseline period was set from May 2012 to August 2012. The intervention period was set from September 2012 to December 2012. The inpatients were the object of this study. The differences of medication error rate and potential error rate between the two periods were analyzed. The types of medication error and potential error and the reporter were analyzed. The effect of intervention was evaluated. Results： The medication error rate in the intervention period （0.16%） was lower than that in the baseline period （ 1.35% ）. The potential error rate in the intervention period （5.20%） was higher than that in the baseline period （0.55%）. The wrong medication time was the main type of medication error in the baseline period. The wrong dosage was the main type of medication error in the intervention period. The pharmacist was the main reporter of the medication error and potential error. Conclusion： A perfect medication error reporting, surveillance and intervention system can effectively reduce the risk of medication errors.