我院门诊207例用药错误分析

Analysis of 207 Cases of Medication Errors in Outpatient Department of Our Hospital

目的:为临床合理用药提供参考。方法:对我院2014年10月-2015年9月门诊药房报告的用药错误(ME)案例进行分析,包括ME分级、分类、发生原因、发生和发现ME的人员情况及构成比。结果:207例报告中无A级错误,B级错误199例,C级错误8例,无D^I级错误。其中,医师处方错误162例(78.26%),药师调剂错误45例(21.74%),排名前3位的医师处方错误依次为用法用量不当(42.59%)、给药途径不当(40.74%)和溶剂不适宜(5.56%);排名前3位的药师调剂错误依次为品种错误(40.00%)、规格错误(28.89%)和数量错误(24.44%)。医师处方错误的原因主要是信息系统不完善(56.17%)和医师不了解药物信息(43.83%);药师调剂错误的主要原因是药品一品多规(35.56%)、名称相似(28.89%)和人员疲劳(26.67%)。发现ME的人员中,药师、护士和患者或家属占比分别为97.58%、1.45%和0.97%。结论:进一步加强医院信息化建设,同时加强医师和药师的在岗培训,可以在一定程度上减少ME的发生。

OBJECTIVE：To provide reference for clinical rational drug use. METHODS：Medication error（ME）cases reported from outpatient department from Oct. 2014 to Sept. 2015 in our hospital were analyzed,including ME category,classification,cause and proportion of persons who triggered or detected ME. RESULTS：Among 207 reports,there was no case of category A,199 cases of category B,8 cases of category C,no of categories D-I. Among them,162 cases occurred in the links of prescriptions by doctors（78.26%）,45 cases（21.74%） occurred in the links of dispensing prescriptions by pharmacists,the top 3 ME were improper usage（42.59%）,improper administration route（40.74%）and inappropriate solvent（5.56%）;the top 3 dispensing errors were variety error（40.00%）,specification error（28.89%）and number errors（24.44%）. The main causes for prescription errors were incomplete information system（56.17%）and drug information missing of doctors（43.83%）;the main causes for dispensing errors were double specifications of drugs（35.56%）,similar drug name（28.89%）and staffsntired（26.67%）. In terms of the persons who triggered ME,the proportions of pharmacists,nurses,patients or their families were 97.58%,1.45% and 0.97%,respectively. CONCLUSIONS：Further strengthening information system and the on-the-job training for physicians and pharmacists can reduce the ME to some extent.