某院住院药房药品调剂差错分析及改进措施

Analysis of drug dispensing errors and improvement measures in an inpatient pharmacy

目的分析住院药房药品调剂差错的类型和原因,提出改进措施,预防和尽量降低差错率。方法对2017~2018年住院药房发药差错登记本上登记的所有药品调剂出门差错进行回顾性分析,统计差错的类型和原因。结果2017~2018年住院药房发生药品调剂出门差错共56例,差错率为0.071‰。其中,药品数量差错发生最多,占比28.57%;其次为药品种类差错,占比25.00%;再次为生产厂家差错,占21.43%。导致调剂差错的原因包括药品名称相似、药品外观相似、摆放位置相近、药师调剂时不专心和其他原因等。结论导致调剂差错发生的原因,可以归结为药品、人员、环境、其他等几方面,针对这些原因,可以实行一系列的改进措施,最大程度地减少药品调剂差错的发生。

Objective To analyzes the types and causes of drug dispensing errors in an inpatient pharmacy,and propose improvement measures to prevent and minimize the error rate.Methods All drug dispensing errors registered in the dispensing errors register of the inpatient pharmacy from 2017 to 2018 were retrospectively analyzed,and the types and causes of the errors were statistically analyzed.Results A total of 56 cases of drug dispensation errors occurred in the inpatient pharmacy from 2017 to 2018,with an error rate of 0.071‰.Among them,the number of drug errors occurred the most,accounting for 28.57%.The second one was drug type error(25.00%).Again for the manufacturer error,accounted for 21.43%.The causes of drug dispensing errors include similar names,similar appearance,near placement,unfocused pharmacists while dispensing and other reasons.Conclusion The causes leading to dispensing errors can be attributed to several aspects,such as drugs,personnel,environment,and others.In view of these causes,a series of improvement measures can be implemented to minimize the occurrence of drug dispensing errors.