儿童用药错误案例分析及药师在错误防范中的作用

Case analysis of children’s medication errors and the role of pharmacists in the prevention of errors

目的通过用药错误案例分析,探讨药师在用药错误识别和防范中的作用。方法采用回顾性研究和描述性的统计方法,对2016年1月至2018年12月国家儿童医学中心首都医科大学附属北京儿童医院上报的用药错误案例进行统计并分析用药错误的级别、类型、引发错误的原因、涉及人员、引发用药错误的药品情况等。结果2016年1月至2018年12月共上报682例用药错误案例,其B级用药错误数量最多,占比98.2%,C级用药错误其次,占比1.8%。用药错误类型中药品用量错误占比最大,占比54.3%;引发用药错误的主要原因为:知识欠缺、技术不熟练,培训不足等;引发差错的人员主要为主治医师及初级药师;药师拦截用药错误605例,占比88.7%。结论儿童用药错误中最常见的是处方环节用量错误。药师对减少用药错误的发生、促进合理用药有着极大的帮助,并具有积极作用。

Objective By analyzing the cases of medication error reported by our hospital,the role of the pharmacist in the identification and prevention of medication errors were discussed.Methods A retrospective study and a descriptive statistics method were used to make statistics on the cases of medication error reported by Children’s Natienal Medical Center,Beijing Children’s Hospi- tal Affiliated to Capital Medical University from January 2016 to December 2018,and analyze the level and type of medication error,the cause of the error,the personnel involved,the drug situation that caused the medication error,and so on.Results A total of 682 cases of medication error were reported from January 2016 to December 2018.The number of B-grade medication errors was the most,accounting for 98.2%,and C-grade medication error was the second,accounting for 1.8%.The proportion of drug usage in the medication error type was the largest,accounting for 54.3%.The main cause of the medication error was:lack of knowledge,lack of skills,insufficient training,etc..The personnel who caused the error were mainly the attending physician and the primary pharmacist.The pharmacist intercepted the medication error in 605 cases,accounting for 88.7%.Conclusion The most common problem in the medication error of children is the wrong dosage of the prescription.The pharmacist are with great help and positive effect in reducing the occurrence of medication errors and promoting the rational use of the medicine,and has a.