某院住院药房818例用药错误分析及对策

Analysis and countermeasures of 818 medication errors in inpatient pharmacy of our hospital

目的分析北京大学国际医院(以下简称“我院”)住院药房用药错误的发生情况,探讨提高患者用药安全的应对策略,提出降低差错发生的对策。方法利用查阅法、回顾性统计分析法对我院2019年11月~2021年6月病房药房登记的用药错误记录进行研究,分析差错原因、归纳相关原因。结果按错误发生环节统计,共收集到818例用药错误,均为未出门差错。在用药错误分级管理中A级71例、B级747例,无C级以上用药错误。用药错误分类中全部来自调剂差错,差错类型例数由高到低依次是:药品数量325例次,药品种类322例次,其他94例次,药品规格59例次,药品剂型19例次。结论引起调配差错的因素是多方面的,应针对本医疗机构出现的用药风险隐患开展持续改进,提升医院用药安全为目的,全程防范,闭环管理。

Objective To analyze the occurrence of medication errors in the inpatient pharmacy of Peking University International Hospital(hereinafter referred to as"our hospital"),discusse the coping strategies to improve the medication safety of patients,and put forward the countermeasures to reduce the occurrence of errors.Methods The medication error records registered in the inpatient pharmacy of our hospital from November 2019 to June 2021 were studied by consulting and retrospective statistical analysis,and the causes of errors were analyzed and summarized.Results According to the statistics of error occurrence link,818 medication errors were collected,all of which were not going out.In the graded management of medication errors,there were 71 cases of Grade A and 747 cases of grade B,and there were no medication errors above grade C.In the classification of medication errors,all of them came from dispensing errors.The number of cases of error types from high to low was:325 cases of drug quantity,322 cases of drug type,94 cases of others,59 cases of drug specification,and 19 cases of drug dosage form.Conclusion There are many factors causing deployment errors.Continuous improvement should be carried out for the hidden dangers of drug utilization in the medical institution to improve the safety of drug utilization in the hospital,with the whole process prevention and closed-loop management.