探讨病区药房药品调剂差错原因及其防范对策

Investigation on causes of drug dispensing errors in ward pharmacies and its preventive measures

目的分析病区药房药品调剂差错原因,并制定相应的防范对策。方法选择病区药房药品出现调剂差错的59张处方,通过回顾性分析法调查药品调剂差错原因,记录不同差错原因的发生率。结果59张处方中,药师因素的差错率为49.15%,药品因素的差错率为18.64%,医师因素的差错率为32.20%。药师因素中,责任心差错率为79.31%,药品位置差错率为20.69%。药品因素中,药品外包装相似差错率为27.27%,药物商品名称相似差错率为18.18%,同名不同规格差错率为54.55%。医师因素中,医嘱单有误差错率为5.26%,剂量、规格、用法错误差错率为21.05%,用法不正确或不清楚差错率为15.79%,配伍禁忌差错率为57.89%。结论医院病区药房合理分析药品调剂差错原因,可以采取有效措施来防止差错的发生。

Objective To analyze the causes of drug dispensing errors in ward pharmacies and make corresponding preventive measures.Methods 59 prescriptions with drug dispensing errors from the ward pharmacies were selected as the study subjects.The causes of drug dispensing errors were investigated by retrospective analysis,and the incidence of different error causes was recorded.Results In 59 prescriptions,the error rate of pharmacist factor was 49.15%,the error rate of drug factor was 18.64%and the error rate of physician factor was 32.20%.Among the pharmacist factors,the error rate of responsibility was 79.31%,and the error rate of drug location was 20.69%.Among the drug factors,the error rate of similar drug packaging was 27.27%,the error rate of similar drug name was 18.18%,and the error rate of different specifications with the same name was 54.55%.Among the physician factors,the error rate of doctor's order was 5.26%,the error rate of dosage,specification and usage was 21.05%,the error rate of incorrect or unclear usage was 15.79%,and the error rate of incompatibility was 57.89%.Conclusion Reasonable analysis of causes of drug dispensing error in ward pharmacies,so that effective measures can be taken to prevent the occurrence of errors.