某医院临床用药错误分析及防范措施

Analysis of Clinical Medication error and prevention strategies in a hospital

目的调查濮阳市人民医院临床用药错误(medication error,ME)的发生情况,为医院制定防范措施提供依据。方法收集2020年1月至2023年5月濮阳市人民医院临床用药错误案例,采用回顾性研究和描述性统计方法,分析ME的分级、内容、发生原因、相关药品、对患者造成的伤害情况、引发人员和发现人员的例次及其构成比。结果共收集ME 74例,其中B级50例,C级18例,D级3例,E级3例,无A级及F级以上ME。引发ME的人员中,药师、医师、护士分别占比87.84%、8.11%、4.05%。ME类型中,药物品种错误发生率最高(29例,占比39.19%),其次为药品规格错误(12例,占比16.22%)、患者身份识别错误(7例,占比9.46%)。ME引发因素中,药师未遵循标准操作规程发生率最高(33例,占比44.59%),其次为多规格(9例,占比12.16%),药品名称相似(8例,占比10.81%)。结论医疗机构需进一步提高对ME的重视程度,加强医院药学人才队伍建设,强化对医务人员安全用药技能培训,制定合理的防范措施,减少ME的发生。

Objective To investigate the occurrence of medication errors(ME)in Puyang City People's Hospital,and provide the basis for the formulation of preventive measures.Methods ME cases reported from January 2020 to May 2023 in our hospital were collected.The ME classification,contents,Related drugs,triggering factor of ME,harm to the patients,the number and proportion of persons who caused or detected ME were analyzed by retrospective study and descriptive statistical method.Results Totally 74 cases of medication errors were collected,Including 50 cases of category B,18 cases of category C,3 cases of category D,3 cases of category E,there was no case of category A and F-I.In terms of the persons that triggered ME,the proportion of pharmacists、physicians、nurses were 84.47%、8.11%、4.05%respectively.Among the ME types,The incidence of drug variety errors was the highest,reaching 39.19%(29 cases),followed by drug specification errors of 16.22%(12 cases)and patient identification errors of 9.46%(7 cases).Among the triggers factors of ME,pharmacists did not follow the standard operating procedures for the highest,reaching 44.59%(33 cases),followed by multiple specifications,accounted for 12.16%(9 cases),similarily drug name accounted for 10.81%(8 cases).Conclusion medical institution should pay more attention to the ME,Strengthening the construction of hospital pharmacy talent team and the training on safe medication skills,formulate reasonable preventive measures to reduce the occurrence of ME.