我院2016-2017年用药错误报告分析

Analysis of reports on medication error in our hospital from 2016 to 2017

目的了解我院用药错误(Medication error,ME)报告情况,为医院制定针对性的防范措施提供依据。方法收集我院2016年1月至2017年12月上报的ME报告。采用回顾性研究和描述性统计方法,分析ME的分级、错误内容、引发因素、引发人员和发现人员的例次及构成比例。结果2016-2017年我院共收到合格ME报告1362例。B、C、D、E、F、H级ME分别占86.86%(1183例)、9.62%(131例)、2.35%(32例)、0.81%(11例)、0.29%(4例)、0.07%(1例),没有A、G、I级的报告。从错误内容统计,用量错误比例最高,占32.18%(455例次),其次是给药频次和重复用药,分别占13.15%(186例次)、7.00%(99例次)。从ME引发因素统计,排在前3位的因素为知识欠缺、疲劳和培训不足,分别占42.58%(671例次)、14.40%(227例次)和13.45%(212例次)。引发ME人员中,医师、药师、护士、患者或家属、厂家占比分别为88.75%、8.63%、1.49%、0.99%、0.14%。发现ME人员中,药师、医师、护士、患者或家属占比分别为88.33%、8.89%、1.60%、1.18%。结论我院ME以B级为主,错误内容以用量错误为主,引发ME的主要人员为医师和药师,主要引发因素为专业知识欠缺和疲劳,药师在及时发现和纠正ME中起到重要作用。

Objective To obtain the information of medication error(ME)reports in our hospital and provide basis for the hospital to establish targeted preventive measures.Methods All ME reports from January 2016 to December 2017 were collected from our hospital.The ME categories,contents,factors,and the numbers and proportion of staff who caused or detected ME were analyzed by retrospective study and descriptive statistical method.Results A total of 1362 qualified ME reports were received in our hospital from 2016 to 2017.Category B,C,D,E,F,and H of ME reports accounted for 86.86%(n=1183),9.62%(n=131),2.35%(n=32),0.81%(n=11),0.29%(n=4),and 0.07%(n=1),respectively.Category A,G,and I of ME reports has not been reported.Dosage errors hold the highest proportion,accounting for 33.26%(n=453),followed by wrong frequency and repeated medication errors from the error contents,accounting for 13.66%(n=186)and 7.00%(n=99),respectively.The top three factors were lack of knowledge,fatigue and lack of training,accounting for 42.58%(n=671),14.40%(n=227)and 13.45%(n=212),respectively.The proportion of physicians,pharmacists,nurses,and patients or their families and manufacturers were 88.75%,8.63%,1.49%,0.99%and 0.14%,respectively according to the staff who cause ME.The proportion of pharmacists,physicians,nurses,and patients or their families who detected ME accounted for 88.33%,8.89%,1.60%and 1.18%,respectively.Conclusion Category B of ME is the main errors in our hospital.The dosage error is the main ME based on error content.Physicians and pharmacists are the main staff who cause ME.The main factors are lack of professional knowledge and fatigue.Pharmacists play an important role in detecting and correcting ME.