中药用药错误报告477例分析  

Analysis on 477 medication error reports of traditional Chinese medicine

作　　者：陈新彤[1] 庄伟[1] 王雅葳[1] 周京燕[1] 林晓兰[1] 

机构地区：[1]首都医科大学宣武医院药学部,北京100053

出　　处：《药物不良反应杂志》2016年第4期255-260,共6页Adverse Drug Reactions Journal

摘　　要：目的了解医院中药用药错误（ME）现状及其影响因素。方法自临床安全用药监测网收集首都医科大学宣武医院2014年1月1日至12月31日上报的ME报告，从中筛选出中药ME报告，主要就错误的分级、内容、引发人员、引发因素、发现人员等进行分析。结果共收集到ME报告863份，其中中药ME报告477份，占55．27％。477份中药ME报告中，中成药ME报告180份（37．74％），中草药ME报告297份（62．26％）。所涉及的477例患者中，男性218例（45．70％），女性221例（46．33％），性别不详者38例（7．97％）；年龄4～92岁，≥66岁老年患者113例（23．69％）。477例ME中A级错误83例（17．40％），B级389例（81．55％），C级5例（1．05％），均未导致患者伤害。错误内容以用量错误居首位，占31．03％（148／477）；其次是品种错误，占12．16％（58／477）。引发错误人员中医师占68．13％（325／477），药师占23．06％（110／477）。477例ME中467例由单一因素引发，28例由2个因素引发，10例由3个因素引发，共525例次，其中以中医药专业知识欠缺居首位，占24．57％（129／525）；其次是疲劳，占17．72％（93／525）。发现错误人员主要是中、初级药师，分别占61．49％（289／470）和36．81％（173／470）。结论中药ME约占医院所有ME的半数，其中以中草药ME占多数。引发中药ME的主要人员为医师和药师，主要引发因素为中医药专业知识欠缺和疲劳。药师及时发现和纠正中药ME对保障患者的用药安全起到重要作用。Objective To investigate the status and influencing factors of medication error （ME） in traditional Chinese medicine. Methods ME reports in Xuanwu Hospital of Capital Medical University from January 1st, 2014 to November 31st, 2014 were collected from International Network for the Rational Use of Drugs （INRUD）. Of them, ME reports of traditional Chinese medicine were selected. Category, content, persons who triggered the ME, triggering factor, persons who found the ME were analyzed descriptively. Results A total of 863 ME reports were collected and 477 reports （55.27%） related to traditional Chinese medicine were selected. Of the 477 ME reports, 180 reports（37.74% ） were related to Chinese patent drugs and 297 reports （ 62.26% ） were related to Chinese herbal drugs. Four hundred and seventy-seven patients were reported in the 477 ME reports. Of the 477 patients, 218 patients （45.70%） were male, 221 （46.33%） were female, and in 38 （7.97%） the sex was not clear. Their ages were from 4 to 92 years and 113 patients（23.69%） were ≥66 years old. Of the 477 MEs, 83 cases （17.40%） belonged to category A, 389 cases （81.55%） belonged to category B, 5 cases （ 1.05% ） belonged to category C, and none of the patients were hurt. The dosage errors in content of MEs ranked the first and accounted for 31.03% （148/477） , errors of drug category ranked the second and accounted for 12.16% （58/477）. In persons who triggered the ME, doctors accounted for 68. 13% （325/477）, pharmacists accounted for 23.06% （110/477）. Four hundred and sixty-seven cases of the 477 MEs were caused by a factor, 28 cases were caused by 2 kinds of factors, 10 cases were caused by 3 kinds of factors, and a total of 525 person-time MEs were reported. Lack of professional knowledge of traditional Chinese medicine was the first triggering factor and accounted for 24.57% （ 129/525 ）, fatigue was the second triggering factor and accounted for 17.72% （93/525）. The main persons who found the ME

关 键 词：用药错误 中草药 中成药 

分 类 号：R288[医药卫生—中药学]