门诊药房药品调配差错及防范措施的系统性分析

Systematic analysis of drug dispensing errors and preventive measures in outpatient pharmacies

目的了解国内医院门诊药房调配差错及有效防控措施现状,以期进一步提高药品调配工作质量。方法检索中文期刊数据库2015—2020年二、三级医院门诊药房调配差错及其采取措施后的质量持续改进的文献,汇总分析改进前后不同差错类型及其数量,原因分析及其改进措施等内容。结果检索得到的146篇文献中纳入分析的有13篇(三级医院11篇,二级医院2篇)。改进前,药品调配差错率的中位数为5.1‰,改进后为1.1‰。改进前后,药品调配差错类型构成主要为数量差错(52.5%对51.3%)、品种差错(28.3%对28.7%)、规格剂型差错(6.2%对6.7%)、标签差错(2.1%对2.9%)。针对调配差错原因采取的改进措施重叠率较高,集中在人员因素和药品因素两方面。结论医院门诊药房采用质量持续改进工具开展对调配差错的控制防范依然是当前研究的热点;改进后的错误类型构成基本没有变化;执行标准化操作规程等持续改进综合措施可以有效降低调配差错发生率,有助于《中国用药错误管理专家共识》的落地。

Objective To understand the current situation of dispensing errors and effective prevention and control measures in outpatient pharmacies in domestic hospitals,in order to further improve the quality of drug dispensing.Methods The Chinese journal database was retrieved from 2015 to 2020 for the literature on the dispensing errors of outpatient pharmacies and the continuous improvement of the quality after the measures were taken in secondary and tertiary hospitals.Results Of the 146 literatures retrieved,13 were included in the analysis(11 in tertiary hospitals and 2 in secondary hospitals).Before the improvement,the median of the drug dispensing error rate was 5.1‰,and after the improvement it was 1.1‰.Before and after the improvement,the types of drug dispensing errors were mainly quantity errors(52.5%vs.51.3%),variety errors(28.3%vs.28.7%),specifications and dosage forms errors(6.2%vs.6.7%),and labeling errors(2.1%vs.2.9%).The improvement measures taken for the reasons of dispensing errors have a high overlap rate,and they are concentrated in two aspects:personnel factors and drug factors.Conclusion The use of continuous quality improvement tools in hospital outpatient pharmacy to control and prevent dispensing errors is still a hotspot of current research.The composition of the types of errors after improvement has basically not changed.The implementation of standardized operating procedures and other continuous improvement comprehensive measures can effectively reduce the incidence of dispensing errors,and contribute to the implementation of the“Expert Consensus on Medication Error Management in China”.