门诊药房非惩罚性调剂差错报告130例分析

Analysis of 130 cases of non-punitive drug dispensing errors at outpatient pharmacy

目的分析门诊药房药品调剂差错发生情况及改进方向。方法收集民航总医院药剂科2012年2月至2013年1月门诊药房非惩罚性用药错误报告系统的报告,筛选出调剂差错,按照差错发生率、差错分级、差错内容、引发差错原因、差错发生时间、差错药品分类及引发和发现差错人员进行分析。结果共纳入130例调剂差错报告。2012年2月、7月和8月差错报告较多,差错发生率分别为0.037%、0.022%及0.034%,全年调剂差错发生率0.009%。130例报告中,A、B及C级差错分别为4例(3.1%)、120例(92.3%)及6例(4.6%)。126例B及C级差错报告的引发人员依次为初级药师(108例)、实习人员(13例)和中级药师(5例),发现人员依次为中级药师(95例)、初级药师(30例)、护士(2例)、患者(2例)和高级药师(1例);差错内容以药物品种差错最为多见,占73.8%。130例报告中,以药名相似为错误原因者最多,占34.6%。差错发生时间主要集中在8:00至10:59及13:00至14:59。126例B级及C级报告中,西药、中成药、高危药品和麻醉药品差错报告占比分别为57.9%(73例,涉及129种药品)、38.1%(48例,涉及74种药品)、3.2%(4例,涉及3种药品)和0.8%(1例,涉及2种药品)。结论可通过更新设施、规范药品摆放、优化工作规范和流程、加强教育培训、建设非惩罚性安全用药文化等措施防范调剂差错。

Objective To analyze occurrence situation and improvement direction of drug dispensing errors at outpatient pharmacy. Methods Reports in non-punitive medication error reporting system at outpatient pharmacy of Civil Aviation General Hospital from February 2012 to January 2013 were collected. Cases of drug dispensing errors were selected and analyzed according to incidence, category, content, triggering cause, occurrence time, and drug classification of en＇ors and persons who triggered or detected errors. Results One hundred and thirty cases of drug dispensing errors were included. Error cases occurred mainly in February, July, and August and the incidences were 0. 037% , 0. 022% , and 0. 034% , respectively. The incidence of drug dispensing errors in the whole year was 0. 009%. Of the 130 cases, errors of category A, B, and C were respectively 4 cases （3. 1%）, 120 cases （92.3%）, and 6 cases （4.6%）. The persons who triggered errors of 126 cases of category B and C were respectively elementary pharmacists （ 108 cases） , interns （ 13 cases） , and intermediate pharmacists （5 cases）. The persons who detected errors of 126 cases of category B and C were respectively intermediate pharmacists （95 cases）, primary pharmacists （30 cases）, nurses （ 2 cases）, patients （ 2 cases）, and senior pharmacist （ 1 case）. The most common errors content was errors of drug varieties which accounted for 73.8%. Of the 130 cases, sound-alike drugs caused the most errors which accounted for 34.6%. The errors occurred mainly from 8：00 to 10：59 and from 13：00 to 14：59. Of 126 cases of category B and C, proportions of western medicine, Chinese patent medicine, high-risk drug, and narcotic drug were respectively 57.9% （73 cases, involving 129 kinds of drugs） , 38.1% （48 cases, involving 74 kinds of drugs）, 3.2% （4 cases, involving 3 kinds of drugs ） , and 0.8% （1 case, involving 2 kinds of drugs ）. Conclusion Drug dispensing errors could be prevented by renewing facility, managing drug location, optimizing work norm and procedure, strengthening education and training, and constructing culture of non-punitive drug safety.