某中医院500例用药错误隐患的发现与分析

500 medication errors in traditional Chinese hospital by root cause analysis

目的研究某中医医院用药错误(ME)发生的原因并分析其对策。方法采用根本原因分析法(RCA)回顾性分析2016年1-6月500例ME,分析其发生的原因。结果 ME主要发生在诊室和药房,分别占72.00%和27.40%。中成药ME共105例,化药ME共395例,两者错误分级及错误构成相似。药品品种错误比例最高占25.00%,其次为药品数量错误为19.60%,药品用量错误第三,占13.20%。疲劳为引发ME最主要原因,占32.20%,其次为知识欠缺和技术不熟练。医师占ME引发人员63.40%,药师占35.60%。发现ME的人员药师占81.20%,护士占16.80%。结论应加强医院信息系统权限设置及维护,增加ME相关培训,制定管理制度激励医务人员上报ME,加强医务人员相关药学知识培训等措施来减少ME的发生。

Objective To determine the reasons for medication errors （ME） in a traditional Chinese hospital. Methods Totally 500 cases of ME from January 2016 to June 2016 were retrospectively analyzed by root cause analysis （RCA）. Results ME mainly occurred in the cousultation rooms and pharmacy, accounting for 72.00% and 27.40% respectively. Chinese medicine ME reached 105 cases, and the other 395 MEs were chemical drugs, with similar error classification and error constitute. The highest proportion of drug variety accounted for 25.00%, followed by wrong number of drugs （19.60%）, and drug dosage （13.20%）. Fatigue was the main cause of MEs （32.20%）, followed by the lack of knowledge and unskillful technology. Physicians were responsible for 63.40% of the ME, while pharmacists for 35.60%. Those who detected ME included pharmacists （81.20%）, and nurses （16.80%）. Conclusion It is necessary to strengthen the establishment and maintenance of hospital information system authority, increase ME related training, formulate management system to encourage medical personnels to report ME, and increase pharmaceutical knowledge training to reduce MEs.