医院用药错误524例回顾性分析及防范措施

Retrospective analysis and preventive measures of 524 cases of medication errors in hospitals

目的了解皖南医学院第一附属医院用药错误发生情况,以期降低错误发生率,保障患者用药安全,提升患者的就医满意度。方法收集2018年1月-2019年12月皖南医学院第一附属医院的用药错误报表,并对其进行回顾性统计分析,记录用药错误的分级、引发人员及报告人、用药错误分类、引发因素、药物类别。结果共收到用药错误报告524例,517例(98.7%)第二层级错误,7例(1.3%)第三层级错误,未收到第一层级和第四层级的错误报告。524例错误报告中,主要引发人员是医师480例(91.6%),主要报告人员是药师460例(87.8%)。发生率最高的用药错误类型是用法错误246例(46.9%),其次是相互作用182例(34.7%)。524例错误报告中,引发因素主要是是人员因素396例(75.6%)和环境因素84例(16.0%)。524例错误报告中,位居前三的药物种类分别是心血管药物233例(44.5%)、中枢神经系统药物92例(17.6%)以及调节水电解质和酸碱平衡药物37例(7.1%)。结论为防范用药错误,制定积极有效的干预措施,定期进行合理的用药知识培训和药品知识培训,加大临床合理用药宣传,规范药品管理以及药品摆放,建立完善的用药错误监测系统以及报告体系,从而保障患者临床用药安全,提升患者的满意度。

Objective To understand the situation of medication errors in the First Affiliated Hospital of Wannan Medical College in orderto reduce the incidence of errors,ensure medication safety and improve the satisfaction of patients.Methods The medication error reports from January of 2018 to December of 2019 in the First Affiliated Hospital of Wannan Medical College were collected,then retrospective analysis was performed,and the evaluation was repeated.The classification of the medication errors,the triggering personnel and the reporter,the misclassification of the medication,the triggering factors and the drug category were recorded.Results A total of 524 medication error reports were received,517 cases(98.7%)were second-level errors,7 cases(1.3%)were third-level errors,and no first-level and fourth-level error reports were received.Among the 524 error reports,the main cause was physician in 480(91.6%),and the main report was pharmacist in 460(87.8%).The highest incidence of medication errors were 246 cases(46.9%)of usage errors,followed by 182 cases of interaction(34.7%).Among the 524 error reports,the main causes were 396 cases(75.6%)of human factors and 84 cases(16.0%)of environmental factors.Among the 524 wrong reports,the top three types of drugs were 233 cases of cardiovascular drugs(44.5%),92 cases(17.6%)of central nervous system drugs,and 37 cases(7.1%)of drugs that regulate water,electrolyte and acid-base balance.Conclusion In order to prevent medication errors to develop positive and effective interventions,strengthen education and training of rational drug use and drug knowledge,increase the clinical use of drugs advocacy,standardize the placement of drugs,establish a sound system of medication error monitoring and reporting system,which protect patient medication safety,so as to enhance patient satisfaction.