医院用药差错的系统分析与对策

Systematic analysis and countermeasures for hospital medication errors

目的:分析某省级三甲医院药疗实践中出现的用药差错情况,提高药学服务水平和药师调剂质量,减少医疗安全隐患,促进医院医疗质量提升。方法:汇总该院2012年9月1日-2013年8月31日出现的用药差错,采用美国国家用药差错报告和预防协调委员会(NCC-MERP)用药差错分级方法进行汇总,分析用药差错产生的原因,提出适当的防范措施和对策。结果:本研究共收集332例用药差错,占总调剂总量的0.11‰。按照不同分类方法汇总分析发现:98.2%(326)的差错未造成患者伤害;内部差错与出门差错比例为291∶41;差错发生率最高的为药师调配数量差错,占到33.4%;鱼骨图分析得出人、事、物为造成调配数量差错的三个主要原因。结论:用药差错是客观存在的,医院应当在建立现代的非惩罚性用药差错事件上报制度上,采取鼓励措施促使医务人员积极自愿上报用药差错事件,并利用质量管理工具全面分析和防范用药差错。

OBJECTIVE To analyze the medication errors in a first-class provincial hospital to improve service level of pharmacy and preparation quality of pharmacist,reduce hidden dangers of medical security,and promote improvement of medical quality in hospitals.METHODS Medication errors between September 1^st,2012 and August 31^st,2013 were summarized in the hospital.All the medication errors were categorized and analyzed according to the method development by National Coordinating Council for Medication Error Reporting and Prevention（NCC-MERP）to analyze the reasons for medication errors,and propose proper countermeasures.RESULTS A total of 332 medication errors were collected,accounted for 0.11% of total number of dispensation.According to the different categorizing methods,98.2%（326）had not caused harm to patients.The ratio of internal error and external error was 291∶41.Dispensing error by pharmacist accounted the highest proportion,accounting for 33.4%.By fish bone analysis,people,event and item were the three major reasons for dispensing errors.CONCLUSION Medication errors are objective.The hospital should establish modern non-punitive error event reporting system,adopt encouraging measures to promote medical staff to voluntarily report medication errors,and utilize quality administration tolls to comprehensively analyze and prevent medication errors.