全国临床安全用药监测网年度报告(2023年)

Annual report of National Monitoring Network for Clinical Safe Medication(2023)

全国临床安全用药监测网2023年收到全国27个省级行政区439家医院的用药错误(ME)报告27742例。其中A级错误282例(1.02%),B级22452例(80.93%),C级4239例(15.28%),D级499例(1.80%),E级141例(0.51%),F级127例(0.46%),G级1例(<0.01%),I级1例(<0.01%),无H级病例发生。B~I级ME涉及的27460例患者中,男性15131例(55.10%),女性12329例(44.90%);年龄1 d~103岁,其中儿童(<18岁)3198例(11.65%),青中年人(≥18~<60岁)12576例(45.80%),老年人(≥60岁)11686例(42.56%)。错误内容居前3位者分别为品种(5880例次,20.97%)、用量(4668例次,16.65%)和给药频次(3184例次,11.35%)。导致患者伤害的严重ME(E~I级)涉及270例患者,男性140例(51.85%),女性130例(48.15%);年龄52 d~94岁,其中儿童31例(11.48%),青中年人91例(33.70%),老年人148例(54.82%);所涉药品在前3位者依次为头孢哌酮钠舒巴坦钠、二甲双胍和艾司唑仑,1例致死ME为误将复方荆芥熏洗剂口服所致。27460例B~I级ME中,引发错误人员主要为医师(19655例,71.58%)和药师(5688例,20.71%),少数为护士和患者/家属等。ME发生场所主要为门诊(10537例,38.37%),病房(8187例,29.81%),药房(6470例,23.56%);270例严重ME中121例(44.81%)发生场所是患者家中。错误发现人员居前3位者分别是药师20693例次(74.46%),患者/家属3240例次(11.66%),医师2214例次(7.97%)。引发错误因素居前3位者分别是知识欠缺(9382例次,28.35%)、疲劳(5974例次,18.05%)和培训不足(3831例次,11.58%)。针对2023年发生率较高和较严重的ME,以下风险需要加强防范,包括外用药误为内用、误服外包装、儿童用量剂量换算错误、特殊给药频次错误、肠内营养制剂和刺激性静脉制剂的滴注速度过快、蒙脱石散和其他药物相互作用、磷霉素钠导致高钠血症等。此外,加强频发严重ME及致死ME药物品种的管理,以及对患者的科普和安全用药教育等,有助于保障患者用药安全。

In 2023,a total of 27742 cases of medication error(ME)from 439 hospitals in 27 pro⁃vincial administrative regions were collected in the National Monitoring Network for Clinical Safe Medica⁃tion.Among them,282(1.02%)were classified as grade A,22452(80.93%)as grade B,4239(15.28%)as grade C,499(1.80%)as grade D,141(0.51%)as grade E,127(0.46%)as grade F,1(<0.01%)as grade G,and 1(<0.01%)as grade I;no MEs of grade H occurred.Among the 27460 patients involved in MEs of grade B to I,15131(55.10%)were male and 12329(44.23%)were female;their ages were from 1 day to 103 years;3198(11.65%)were children(<18 years old),12576(45.80%)were young and middle⁃aged adults(≥18 to<60 years old),and 11686(42.56%)were elderly(≥60 years old).The top 3 contents of ME were wrong drug class(5880 cases,20.97%),wrong dosage(4668 cases,16.65%),and wrong administration frequency(3184 cases,11.35%).A total of 270 patients were involved in severe MEs(grade E⁃I),including 140(51.85%)males and 130(48.15%)females,aged from 52 days to 94 years,of which 31(11.48%)were children,91(33.70%)were young and middle⁃aged adults,and 148(54.82%)were elderly.The top 3 drugs involved were cefoperazone sodium and sulbactam sodium,metformin,and estazolam.One fatal ME was caused by mistakenly orally taking Fufang Jingjie for fumigation and washing.Among the 27460 grade B⁃I MEs,19655(71.58%)were triggered by physicians,5688(20.71%)by pharmacists,and few by nurses,patients and their family members,etc.These MEs mainly occurred in clinics(10537 cases,38.37%),in hospital wards(8187 cases,29.81%),and in pharmacies(6470 cases,23.56%).But among the 270 severe MEs,121(44.81%)occurred in the patient′s home.The top 3 persons who discovered the ME were phar⁃macists(20693 cases,74.46%),patients and their family members(3240 cases,11.66%),and physicians(2214 cases,7.97%).The top 3 factors causing ME were lack of related pharmacologic knowledge(9382 cases,28.3%),tiredness(5974 cases,18.05%),and insufficient training of medical workers(3831 cases,11.58%).In view of MEs with high incidence or more severe in 2023,relevant risks should be paid attention to,including misusing external drugs for internal use,ingestion of drug packaging by mistake,wrong dose conversion in children,ME in special dosing frequency,too fast infusion speed of enteral nutrition prepara⁃tions and irritant intravenous preparations,interaction between montmorillonite powder and other drugs,hypernatremia caused by fosfomycin sodium,etc.In addition,strengthening the management of drug varieties with frequent severe MEs and fatal MEs,as well as the popular science and safe drug use education for patients,can help ensure the medication safety of patients.