828例用药错误分析及防范策略

Analysis of 828 Cases of Medication Errors and Preventive Strategies

目的:了解北京医院(以下简称“我院”)用药错误(medication error,ME)的发生情况,探讨保障患者安全用药、防范错误的策略。方法:收集2016年1月至2019年9月我院上报的ME,采用回顾性分析方法,记录ME的分级、内容、引发因素、发现人员以及错误相关药品等内容。结果:共收集到828例ME,其中A级2例,B级811例,C级15例,无D级以上ME。ME内容统计中,药物用量错误发生率最高(187例次,占总例次数833例次的22.45%),其次为品种错误(170例次,占总例次数833例次的20.41%)、重复给药错误(101例次,占总例次数833例次的12.12%)。ME的引发因素中,技术不熟练引发的ME最多(255例次,占总例次数919例次的27.75%),其次为知识欠缺(241例次,占总例次数919例次的26.22%)。828例ME中,引发ME的人员主要为医师(490例,占59.18%);药师发现并上报的ME最多(564例,占68.12%)。ME报告中涉及药物以心血管系统用药最多。结论:我院应加强医师和药师的专业技能培训,同时进一步优化医院信息化管理系统,以减少ME的发生,保障患者安全用药。

OBJECTIVE:To investigate the occurrence of medication errors(ME)in Beijing hospital(hereinafter referred to as“our hospital”),and explore strategies to ensure medication safety and prevent errors.METHODS:ME reported from Jan.2016 to Sept.2019 in our hospital were collected.Retrospective analysis was performed to record the categories,contents,triggers,discoverers,and error-related drugs of ME.RESULTS:Totally 828 cases of ME were collected,including 2 cases of category A,811 cases of category B,15 cases of category C,category D and above was not reported.In terms of the ME contents,the proportion of drug dosage error was the highest(187 case-times,accounting for 22.45%of the total 833 case-times),followed by drug variety error(170 case-times,accounting for 20.41%of the total 833 case-times)and the repeated medication error(101 case-times,accounting for 12.12%of the total 833 case-times).Among the triggers of ME,unskilled ME was the most common(255 case-times,accounting for 27.75%of the total 919 case-times),followed by lack of knowledge(241 case-times,accounting for 26.22%of the total 919 case-times).Of the 828 cases of ME,the main cause cases of ME was clinicians(490 cases,59.18%);pharmacists found and reported the most ME(564 cases,68.12%).Among of the ME reports,cardiovascular system drugs were the most frequently error.CONCLUSIONS:Our hospital should strengthen the professional skills training of clinicians and pharmacists,as well as further optimize the hospital information management system in order to reduce the occurrence of ME and ensure the safe medication for patients.