某医院2014年用药错误分析及防范  

作　　者：曹颖[1] 栾海波[1] 孙楠[1] 

机构地区：[1]北京市门头沟区医院,102300

出　　处：《首都食品与医药》2016年第10期68-69,共2页Capital Food Medicine

摘　　要：目的通过对我院提高药品安全管理措施实施后用药错误(ME)报告的相关数据,探讨如何提高ME上报数量、降低ME发生比例、完善ME监测报告工作。方法收集我院2014年上报的药物异常事件处理报告单并进行分析,包括ME发生的环节类型、分类、引发因素和引发及发现ME的人数构成比。结果技术和类型错误中排在前三位的是处方开具与传递、给药与监测、药品调剂与分发,分别占61.3%、30.3%、7.6%。错误内容分析前三位分别是:品种错误(占39.7%)、用量错误(占33.9%)、用法错误(占10.8%)。引发因素中药品因素所占比例最高为40.5%,其次为人员因素占35.1%,再次为环境因素占20.6%。引发人员排在前三位的是医师、护士、药师,分别占引发人员的62.7%、22.7%、1.4%。发现人员中药师比例最高占88.4%。结论用药错误应该引起医疗机构的重视;药师是防止ME发生的关键力量。Objective To discuss ways of increasing submission account, reducing occurrence ratio and improving quality of supervision on medication error （ME） by comparing ME reports before and after execution on drug safety management in Mentougou District Hospital. Method Medication Error Reports in 2013 and 2014 were collected and analyzed, which include ME type, ME classification, trigger factor and constituent ratio of ME reporter. Results Top three errors in technology/type error are prescription/transfer, administration/ monitoring and dispensing/distribution,account for 61.3%, 30.3% and 7.6%. For classification error, the top three are variety error （39.7%）, amount error （33.9%） and usage error （10.8%）. The highest trigger factor is drug factors （40.5%）, followed by human factors （35.1%） and environmental factors （20.6%）. Doctors, nurses and pharmacists are the top three among the human factors, which take 62.7%, 22.7% and 1.4% respectively. The highest proportion among reporters is pharmacist, which is 88.4%. Conclusion Medical institutions need to pay more attention on ME and pharmacist is the key.

关 键 词：用药错误 监测 防范 

分 类 号：R95[医药卫生—药学]