某三甲医院377例用药错误报告分析

Analysis of 377 Reports of Medication Errors in a 3A Hospital

目的分析医院用药错误(ME)的发生规律和特点,提出预防措施。方法收集医院2016年1月至2017年12月发生的ME报告,分析ME的级别、内容、引发错误因素、涉及药品和引发人员。结果 377份报告中,无A级报告,B级313份,C级50份,D级5份,E级8份,F级1份,无G^I级报告;其中,品种错误、患者身份和数量错误报告比例集中,3项累计构成比达56.50%;ME原因主要为药名相似和知识欠缺(占比分别为22.55%和21.75%);引发错误的人员主要为医师(61.01%),其次为药师(36.34%),护士极少。结论进一步加强医院信息化建设,鼓励相关人员积极上报ME,制订有针对性的预防措施,以减少ME的发生,促进临床合理用药。

Objective To analyze the occurrence rules and characteristics of medication errors(ME) in our hospital and put forward preventive measures.Methods The ME reports in our hospital from January 2016 to December 2017 were collected,and the levels,contents,factors causing errors,drugs and personnel involved of ME were analyzed.Results Among 377 reports,there was no case of category A,313 cases of category B,50 cases of category C,5 cases of category D,8 cases of category E,1 case of category F,no case of categories G-I.The proportion of variety errors,patient identity and quantity errors was concentrated,and the cumulative proportion of three errors was 56.50%.The main causes of ME were the similarity of drug names and lack of knowledge(accounting for 22.55%and 21.75%,respectively),the staff who caused the errors were mainly the doctors(61.01%),followed by pharmacists(36.34%) and few nurses.Conclusion The construction of hospital information system should be further strengthened,relevant personnel should be encouraged to report ME actively,and targeted preventive measures should be formulated to reduce the occurrence of ME and promote rational drug use in the clinic.