394例妇幼专科相关用药错误分析

Analysis of 394 Cases of Medication Errors in Women and Children

目的:了解首都医科大学附属北京妇产医院(以下简称“我院”)妇幼专科相关用药错误(medication error,ME)的情况,探讨防范策略,为提高该领域用药安全性提供参考。方法:收集并分析2016—2019年我院在临床安全用药监测网上报的妇幼专科相关ME报告,项目包括ME发生环节、分级、涉及药品、错误内容、引发因素和伤害事件情况等。结果:共收集394例ME,B、C、D和E级ME报告分别占92.39%(364例)、3.81%(15例)、1.78%(7例)和2.03%(8例),无A级和F—I级ME报告;未到达患者的内部差错占90.10%(355例);引发伤害的E级ME中,75.00%(6例)为患者用药错误导致;23.60%(93例)的ME涉及特殊人群(包含妊娠期、哺乳期妇女和婴幼儿)。ME报告数排序居前3位的药品为米索前列醇片、黄体酮软胶囊和地屈孕酮片。统计ME内容发现,医师处方(医嘱)错误最多,集中在用量、给药途径和给药频次;药师调配发药中,品种错误最多;药品使用错误集中在用量和给药技术。引发ME的因素主要为信息系统不完善、知识欠缺和药名相似,形似音似药品主要涉及妇科中成药、雌孕激素和妇科外用药3类。结论:应重视妇幼专科相关ME的防范,制定相关策略,以减少ME的发生。

OBJECTIVE:To investigate the status of medication errors(ME)in women and children in Beijing Obstetrics and Gynecology Hospital,Capital Medical University(hereinafter referred to as"our hospital"),and to discuss the prevention strategies,so as to provide reference for improving medication safety in this field.METHODS:ME reports of our hospital reported on Chinese clinical drug safety monitoring network from 2016 to 2019 were collected and analyzed.Items included the triggering links,classification,involved drugs,error content,triggering factors and injury incidents.RESULTS:A total of 394 cases of ME were collected.ME reports of B,C,D,and E accounted for92.39%(364 cases),3.81%(15 cases),1.78%(7 cases)and 2.03%(8 cases),respectively.There were no ME reports of A and F to I.Internal errors that did not reach the patient accounted for 90.10%(355 cases).Totally75.00%(6 cases)of ME reports of E were induced by the patients’medication error.And 23.60%(93 cases)of ME were special population(including pregnant women,lactating women and infants).The top three drugs ranked by the number of ME reports were respectively Misoprostol tablets,Progesterone soft capsules and Dydrogesterone tablets.In terms of classifications of ME contents,the most errors in clinicians’prescriptions(medical order)were mainly dosage,route of administration and frequency of administration.The error of variety was the most in drug dispensing by pharmacists.Medication errors focused on dosage and administration techniques.The main factors of ME were imperfect information system,lack of knowledge and similar drug names.Drugs with similar appearance and sound mainly involved three categories of Chinese patent medicine for gynecology,estrogen and progesterone and topical drugs for gynecology.CONCLUSIONS:Attention should be paid to the prevention of ME in women and children,and relevant strategies should be developed to reduce the occurrence of ME.