高危药品用药错误致药物损害事件2例分析

Analysis of Two Cases of Adverse Drug Events Induced by Errors in High-alert Medications

报告了2例高危药品用药错误(皮内注射去甲肾上腺素、浓氯化钠封闭注射)导致药物损害事件的实例。药师参与此2例药物损害事件会诊处理,患者恢复良好。建议医院对高危药品加以警示标识,落实安全管理制度。

This article reports two cases of adverse drug events induced by errors in high -alert medications. One case was norepinephrine injection misused intracutaneously and another case was injection of concentrated sodium chloride. The pharmacists took part in the consultation processes of the two cases, the patients recovered well. Herein, we suggest that the high-alert medications should be added with ＂warning signs＂ and its management system be strictly implemented in hospitals.