应用多事件分析框架法分析患者用药错误

Analysis of Medication Errors in Patients by Multi-event Analysis Framework Method

目的:分析医院用药错误的原因和对策,为有效降低药品在临床使用过程中的用药错误提供解决方案。方法:根据中国临床安全用药监测网上报的用药错误报告,应用多事件框架分析法,对其中的药品品种、用法、用量、相互作用、患者身份等项目进行统计分析。结果:患者用药错误内容主要以用量(42%)、相互作用(28.22%)、品种(28%)、用法(11%)为主;导致用药错误发生的人为因素主要为医生处方不清、药师处方审核不严、护士发错药、发漏药、打错针等;导致用药错误发生的环境因素主要为工作环境嘈杂、工作系统复杂等。结论:应用多事件框架分析法可以分析出患者用药错误发生的原因。改进防止用药错误的措施,可以有效降低处方阶段、分配阶段、管理阶段和监测阶段用药错误的发生率。

Objective:To analyze the causes of medication errors in hospitals and to provide countermeasures and solutions to effectively reducing medication errors in clinical use.Methods:Based on the medication error reports of China Network for the Rational Use of Drugs,the multi-event framework analysis method was used to statistically analyze the drug's variety,usage,dosage,interaction,patient identity and other items.Results: The main medication errors lay in dosage (42%),interaction (28.22%),variety (28%),and usage (11%).Human factors leading to medication errors were mainly due to doctors'unclear prescriptions,pharmacist's slack reviews of prescriptions,nurses'wrong distribution,omission or wrong injections,etc.Environmental factors that led to medication errors were mainly ascribed to noisy working environment and complicated working systems,etc. Conclusion:The multi-event framework analysis method can be used to analyze the causes of patients'medication errors.The countermeasures to prevent medication errors can effectively reduce the incidence of medication errors in prescription,distribution,management,and monitoring phases.