1126例用药错误分析与防范措施探讨

1126 cases of medication errors and preventive countermeasures

目的分析本院常见用药错误的现状与特点，探讨相关的防范措施，为保证临床用药安全提供参考。方法采用回顾性研究和描述性统计方法，对本院2015年5月至2017年4月上报的1126例用药错误进行分析，分析项目包括ME的分级、分类、发生错误的药品以及相关的LASA药品、发生错误的场所及引发错误的工作人员职位、引发用药错误的因素等。结果1126例用药差错中，B类用药错误最多，占86．59％，其次是C类，占11．46％，其余类别较少；用药错误内容中最多的是适应证错误（222例，19．72％），其次是给药频次错误（205例，18．21％）、用量错误（188例，16．70％）、给药途径错误（124例，11．01％）、品种错误（104例，9．24％）等；人员因素被认为是引起差错的最主要原因。结论本院用药错误主要为接近错误事件，绝大多数未给患者带来伤害，但潜在危险因素较多，给患者用药安全带来隐患。应通过加强对预防用药错误工具的运用、优化流程加强药师参与以及加强药品管理等方面来进行针对性的调整和改善，提高安全用药水平。

Objective To analyze the present situation and characteristics of medication errors （ME） at our hospital, and to discuss the relevant preventive measures and provide references for the safety of clinical medication. Methods Retrospective study was performed on 1 126 cases of ME reported at our hospital from May, 2015 to April, 2017 by descriptive statistical analysis. The analysis items included the numbers and proportion of ME categories, ME types, ME risk factors, wrong drugs, related LASA drugs, the wrong place and the cause of wrong staff positions, and so on. Results Among the 1 126 cases, the most ME categories were Class B medication error, accounting for 86.59%; followed by class C, accounting for 11.46%; the remaining categories were lower. The proportion of drug indication error was the highest （222 cases, 19.72%）, followed by the frequency of administration error （205 cases, 18.21%）, the dosage error （188 cases, 16.70%）, the wrong route of administration （124 cases, 11.01%）, drug variety errors （104 cases, 9.24%）, and so on. The top factor triggering ME was personal factor. Conclusion Our medication errors were mainly close to the wrong events; the majority did not bring harm to patients, but there were many potential risk factors, so we should make some targeted adjustments and improvements, such as using some tools to prevent the medication errors, optimizing the process to strengthen the participation of pharmacists, and strengthening drug management, so as to improve the level of medication safety.