51例涉药不良事件原因分析及对策  

Analysis and Countermeasures of Drug- Related Adverse Events in 51 Cases

作　　者：邓毅 彭毓芳 贺林 

机构地区：[1]四川省成都市妇女儿童中心医院,四川成都610091

出　　处：《中国药业》2016年第8期77-80,共4页China Pharmaceuticals

摘　　要：目的通过分析51例涉药不良事件,查找发生原因及特点,提出针对性防范措施。方法对某三级医院2013年7月至2014年8月上报的不良事件进行回顾性分析,从中筛选出与药品相关的不良事件,分析其原因及特点。结果涉药不良事件类型及发生频率依次为给药错误(27.45%)、药品调配错误(23.53%)、医嘱错误(21.57%)、输注药品渗漏(13.73%)、其他(13.73%);低工作年限、低职称专业人员不良事件发生率最高;不良事件发生主要原因有制度执行不到位(43.14%)、宣教不到位(23.53%)、部门间缺乏有效沟通(17.65%)、培训不到位(15.69%)。结论管理人员应重视对涉药不良事件的分析,尤其不能忽视护理人员的涉药错误,树立护理人员涉药安全意识,加强对重点人员的培训,查找根源,制订有效措施,营造安全的工作环境,全面防范涉药不良事件的发生。Objective 51 cases of drug-related adverse events were analyzed to find out their causes and characteristics,in order to promote appropriate precautions. Methods Adverse events in a tertiary hospital from July 2013 to August 2014 were studied retrospec- tively. The drug- related adverse events were screened out, and their causes and characteristics were analyzed. Results The type and frequency of drug-related adverse events were the drug administration errors（27.45% ）,drug formulation errors（23.53% ）,prescription errors （21.57%）,leakage of drug infusion（13.73% ）,and others（13.73% ）;staffs with low working years,low professional tides had the highest incidence rate of adverse events. The main reason for adverse events were not fully implementing the system regulations （43.14%）,the education was not in place（23.53% ）,lack of effective communication between departments（17.65% ）,and the training was not in place（15.69% ）. Conclusion Managers should pay more attention to the analysis of drug-related adverse events,especially nurses＇ errors involving drugs,to consolidate the drug-related safety awareness,strengthen the focus on staff training,to find the root causes and develop effective measures to create a safe working environment against drug- related adverse events.

关 键 词：药品不良事件 合理用药 防范措施 

分 类 号：R969.3[医药卫生—药理学] R952[医药卫生—药学]