我院病房退药情况及相关用药差错分析  

Analysis of Returned Medicine and Related Medication Errors in Our Hospital

作　　者：关颖卓[1,2] 邵宏[1] 

机构地区：[1]北京大学药学院药事管理与临床药学系,北京市100191 [2]北京航天总医院,北京市100076

出　　处：《中国药房》2011年第17期1620-1621,共2页China Pharmacy

摘　　要：目的:探讨我院用药流程,分析病房退药情况及因用药差错导致退药的情况。方法:用直接观察法,绘制我院用药流程图,并对2010年1-6月内病房退药申请单的数量、退药品种数、退药影响因素等进行回顾性分析,参照美国卫生系统药师协会(ASHP)用药差错分类,重点分析因用药差错导致的退药。结果:我院用药流程涉及人员有医师、护士、药师等6类,环节有医师诊断、医师选药、医师录入医嘱等13个,存在部分环节不合理、中间环节过多的问题;病房退药占平均每日住院处方数的10.44,退药原因主要有"停药/换药"、"患者出院"、"患者死亡"等;因用药差错导致退药的比例占病房退药总数的6.45,主要包括处方差错、依从性失误和其他类差错,其影响因素主要是计算机系统有缺陷和医患缺乏及时有效的沟通。结论:建议改进用药流程,增强医、护、患之间的沟通,以此降低甚至避免病房退药的发生。OBJECTIVE： To investigate medication workfiow and to analyze the situation of returned medicines and that resulted from medication errors. METHODS： The medication workflow was designed by means of direct observation. The number of returned medicine application, types and influencing factors of returned medicine in wards from Jan. to Jun. in 2010 were analyzed retrospectively. Returned medicines resulted from medication error was analyzed according to ASHP medication error classification. RESULTS： Medication workflow of our hospital involved 6 kinds of staff, such as physicians, nurse and pharmacist. There were 13 links of medication workflow, such as physician diagnosis, drug selection of physician and medication order entering. There were some unreasonable links and excessive intermediate link. Returned medicine of wards occupied 10.44% of average number of inpatient prescription. Main reasons of returned medicine were drug withdrawal or change, patient discharge and patient death, etc. Returned medicines resulted from medication error accounted for 6.45%. The types of medication error were prescribing error, compliance error and others. Main reasons of medication error were system defect and lacking of effective communication between patients and medical staff. CONCLUSION： It is suggested to improve medication workflow and strengthen the communication among physicians, nurses and patients to reduce and aviod the occurrence of drugs returned to pharmacy.

关 键 词：退药 用药差错 用药流程 分析 

分 类 号：R95[医药卫生—药学]