我院用药错误监测5年结果回顾分析

A Retrospective Analysis on Medication Error Monitoring Results in Our Hospital in Five Years

目的:探讨医院药物使用管理系统潜在风险及防范措施。方法:对我院2012年1月1日~2016年12月31日用药错误(ME)监测报告进行回顾性分析,包括ME分级、内容、发生环节、影响因素、发现人员及高警示药品ME分布等。结果:共收集到ME报告425例,其中化学药ME报告311例(73.18%),中药ME报告114例(26.82%);A、B、C级错误分别占4.24%,89.65%,5.41%,D、E、F级各占0.24%,G、H、I级错误未发生;错误内容以品种错误居首位(23.29%),其次为重复用药错误(9.41%)、用量错误(8.94%)等;错误发生环节以处方环节居多(73.18%),其次为调配环节(16.94%);错误影响因素以知识欠缺居首位(26.82%),其次是药名相似(21.41%);错误发现人员以药师为主(93.88%);高警示药品ME共81例,以胰岛素类药品ME(48.15%)和口服降糖药ME(23.46%)居多。结论:通过完善新药遴选与安全评估管理、完善药品信息系统、严格质量管理、强化安全用药宣教,可从一定程度上防范用药错误发生。

Objective： To explore the potential risks in hospital medication management system and propose the preventive measures. Methods： The medication error（ ME） cases reported from Jan 1 st2012 to Dec 31 st2016 in our hospital were retrospectively analyzed in terms of ME category,classification,occurrence link,cause,influencing factors,detecting person and the proportion of highalert medication MEs. Results： A total of 425 ME reports were collected,and among them,311 cases were related to western medicines（ 73. 18%）,and 114 cases were related to traditional Chinese medicines（ 26. 82%）. The proportion of ME in category A,B and C was 4. 24%,89. 65% and 5. 41%,respectively; the proportion of ME in category D,E and F was 0. 24%. ME in category G,H and I was not reported. In terms of the ME classification,the proportion of drug variety error was the highest（ 23. 29%） followed by the repeated medication error（ 9. 41%） and the dosage error（ 8. 94%）. As for the ME occurrence link,the proportion of prescription error was the highest（ 73. 18%） followed by the dispensing error（ 16. 94%）. The top factor to trigger ME was lack of knowledge（ 26. 82%） followed by the similar drug name（ 21. 41%）. The main person who detected ME was pharmacists（ 93. 88%）. Among of the 425 ME reports,81 cases were related to high-alert medication,and the top two were insulin errors（ 48. 15%） and oral hypoglycemic agents errors（ 23. 46%）. Conclusion： It can partly prevent ME by improving selection and management of new drugs,improving drug information system,enhancing drug quality management and strengthening safe medication knowledge education.