我国医疗机构用药错误大数据的分析与启示

Analysis and Explanation of Medication Errors Big Data in Chinese Medical Institutions

目的:分析我国临床安全用药监测网中的用药错误(ME)自愿报告数据,为制定ME防范策略提供依据。方法:采用回顾性研究和描述性统计方法。分析ME的分级、分类、引发因素、引发人员的例次及其构成比。ME分级参照《中国用药错误管理专家共识》标准,分为4层9级。结果:共分析全国19个省市657家医疗机构的11 792例ME报告。ME分级中,未到达患者的内部差错(A级+B级)比例为80.05%;未给患者带来伤害的接近错误(第一层+第二层)比例达99.26%;第三层ME对患者造成一定伤害,占比0.74%;未收到第四层死亡报告。ME分类中,用量错误、品种错误、给药频次、数量和给药途径错误报告比例集中,5项累计构成比例达59.73%。ME引发因素中,人员因素和药品因素被报告者认为是引起差错的重要原因。其中音似形似药品引起的ME占到18.98%。ME引发人员中,由于监测网数据主要由药师报告,因此发现的医生ME最多,达60.95%,其次为药师34.57%,护士极少。结论:ME大数据一定程度上反映了我国用药安全的现状,尤其是医师处方和药师调剂这两个环节的真实情况。医疗机构应将信息化防范用药错误和持续的教育培训作为工作重点。

Objective： To analyze voluntary reporting data of medication error（ ME） in Chinese clinical drug safety monitoring network and provide the support for the development of ME protection policy. Methods： The retrospective study approach and descriptive statistical analysis was used. The numbers and proportion of ME categories,ME types,ME risk factors,ME staff factors were calculated. ME was 4 hierarchies and 9 categories according to Expert consensus on medication error management in China. Results： 11 792 cases of ME were reported in 657 hospitals of 19 provinces in China. In terms of ME categories,the proportion of internal error（ Category A and B） which error was not reach to patient was80. 05%. the proportion of near miss,the first and second hierarchy,which error without harm was 99. 26%. The proportion of third hierarchy which error with harm was 0. 74%. There were not the forth hierarchy ME report which error resulting in death. In terms of ME classifications,the ME with wrong dose,wrong drug,wrong frequency,wrong quantity and wrong route were 59. 73%. In terms of ME risk factors,staff factors and drug factors were the most important reason induce ME.The proportion of look alike and sound alike drug were 18. 98%. In terms of ME staff factors,the proportion of doctors ME was 60. 95% because the data were reported mainly by pharmacists. The proportion of pharmacist ME was 34. 57%. The nurse ME were few. Conclusion： ME Big Data reflected the current situation of drug safety in China,especially prescription and dispensing these two steps. The computerization preventing ME and continuing education and training should put at priority in medical institution.