23例严重用药错误文献分析  

Literatures analysis of 23 cases of severe medication errors

作　　者：赵慧[1] 董迪[1] 安瑗[1] 甄健存[1] ZHAO Hui;DONG Di;AN Yuan;ZHEN Jian-cun(Department of Pharmacy, Beijing Jishuitan Hospital, Beijing 100035, China)

机构地区：[1]北京积水潭医院药学部,北京100035

出　　处：《实用药物与临床》2018年第4期444-447,共4页Practical Pharmacy and Clinical Remedies

摘　　要：目的分析用药错误发生的原因及特点,探讨如何减少用药错误的发生。方法对1994-2017年中国期刊全文数据库、万方医学网、Pub Med数据库报道的严重用药错误报告进行统计分析。结果共收集到23例严重用药错误报告,其中E级10例,F级9例,H级3例,I级1例。ME案例错误内容中,品种和用量错误最为常见,各占47.83%;人员因素引发的ME最多,占56.52%;涉及高警示药品8种,占34.78%;涉及药品的剂型以注射剂为主,占78.26%。结论针对E级及以上的错误,医务人员应迅速展开临床救治,使其对患者的伤害降至最低,规范和落实相似药品和高警示药品管理制度,特别关注儿童患者用药,减少用药错误的发生,保障患者安全用药。Objective To analyze the causes and characteristics of medication errors, and explore how to re- duce the occurrence of medication errors. Methods Based on CNKI,Wanfang medicine database and PubMed,litera- tures of severe medication errors from 1994 to 2017 were collected and statistically analyzed. Results A total of 23 ca- ses of severe medication errors were collected,including 10 cases in category E,9 cases in category F,3 cases in catego- ry H,and 1 case in category I. The main medication errors were in varieties and dosages,accounting for 47. 83% re- spectively. The main causes of medication errors were personnel factor,accounting for 56. 52%. Eight kinds of high a- lert medicines were involved, accounting for 34. 78%. The main form of related drugs was injection, accounting for 78.26%. Conclusion Medical personnel should start treatment quickly for medication errors of category E and above to minimize the damage, standardize and implement the management system of look-alike and pronunciation-alike and high alert medicines ,and pay special attention to children＇s medication to reduce the occurrence of medication errors and ensure safe medication for patients.

关 键 词：用药错误 文献分析 安全用药 

分 类 号：R95[医药卫生—药学]