293例药品不良事件中的用药错误再评价

Re-evaluation of Medication Errors in 293 Cases of Adverse Drug Events

目的：了解用药错误在上报的药品不良事件报告中的发生情况及其对患者造成的伤害。方法： 采用回顾性分析方法对2012年9月～2013年8月我院293例药品不良事件中的用药错误进行识别和再评价。结果：293例药品不良事件中≥60岁的患者比例最大，抗感染药的比例最大，给药途径以静脉给药为主。其中混杂38例用药错误（12.97%），以E类用药错误为主。84.21%的用药错误对原患疾病的影响不明显，89.47%的用药错误可自愈或采取一定的措施得到改善。用药错误原因中前3位的为未规范给予预处理药物、已知患者对该药品有ADR发生史，仍再次用药、给药剂量不适宜和静脉滴速过快。结论：加强对药品不良事件报告中用药错误的监测，评价中应注意甄别用药错误因素，减少用药错误。

Objective：：To understand the occurrence of medication errors in the adverse drug event reports and its effect on the patients. Methods： Based on the retrospective analysis, the perspective of medication errors in 293 cases of adverse drug events were identified and re evaluated in our hospital from September 2012 to August 2013. Results： Among 293 adverse drug events reports, the patients of ≥ 60 years occupied the largest proportion. As for the drug varieties, anti infective agents took the leading position. As for the administration route, intravenous drip had the largest share. The classification of 38 cases of medication errors （12.97%） was mainly in Class E. 84.21%of medication errors had no obvious effect on original illness, and 89.47%of medication errors could heal or improve by taking certain measures. The front 3 causes of medication errors were giving no pretreatment drugs normatively, and the drugs in patients with a known history of ADR were still given their inappropriate dose and excessive intravenous drip. Conclusion：It is necessary to strengthen the monitoring of medication errors in adverse drug event reports. More attention should be paid to identifying factors of medication error during evaluation of adverse drug events in order to reduce the occurrence of medication errors.