某院758例用药错误的原因分析

Analysis the Causes of 758 Cases Medication Errors in Hospital

目的 分析医师、护理、药师和患者用药错误（Medication Errors,ME）情况,讨论应由药师主导减少ME的发生.方法 分析某院2009年7月～2014年6月药师审核、调剂处方及与护士和患者的交流中收集到的用药错误病例的原因和构成.结果 ME由医生引起的488例（64.39%）,药师引起的有57例（7.52%）,护理引起的有45例（5.94%）,患者引起的有168例（22.16%）;74.40%的ME发生在第一层级,22.56%的ME发生在第二层级,7.25%的ME发生在第三层级,第四层级未发现.结论 充分发挥药师的药学特长参与临床合理用药和临床药师对患者的健康素养教育,减少ME事件的发生.

Objective Analysis of physician, nurse, pharmacist and patient medication errors, discussion should be dominated by pharmacists to reduce the happening of the ME.Methods Analyzed of a hospital pharmacist review from July 2009 to June 2014, dispensing prescriptions, and communicating with nurses and patients and the reason of medication errors cases collected in composition.Results ME in 488 patients （64.39%）, caused by doctors, pharmacists have caused 57 cases （7.52%）, the nurse of 45 cases （5.94%）, patients caused in 168 patients（22.16%）, 74.40% of ME at the first level, 22.56% of ME in the second level, 7.25% of ME in the third level, the fourth level is not found.Conclusion Give full play to the pharmacists in the pharmacy specialty participation in clinical rational drug use and clinical pharmacists literacy education to the health of patients, reduce the ME.