223例用药错误分析  

Analysis of 223 cases of medication errors

作　　者：张弦[1] 王晓娟[1] 田晶晶[1] 朱锡玲 袁君[1] 黄庆 ZHANG Xian;WANG Xia-juan;TIAN Jing-jing;ZHU XI-ling;YUAN Jun;HUANG Qing(Department of Pharmacy,Huainan First Peaple's Hospital,Anhui Huainan 232007,China)

机构地区：[1]淮南市第一人民医院药学部,安徽淮南232007

出　　处：《临床药物治疗杂志》2019年第12期74-78,共5页Clinical Medication Journal

摘　　要：目的:分析淮南市第一人民医院(以下简称为我院)用药错误(medication errors,ME)报告,防止潜在ME的发生。方法:收集我院2016年11月至2019年2月上报的ME报告,对ME分级、ME涉及的药品、ME涉及的高警示药品和内容、引发ME的因素及其分布情况进行回顾性分析。结果:共上报223例ME报告,根据错误分级,B级占67.26%,C级占17.04%,D级占11.21%,E级占2.24%,F级占2.24%,A、G、H、I级均未有报告;ME共涉及124个药品,排名前3位为0.9%氯化钠注射液、5%葡萄糖注射液及乳酸左氧氟沙星分散片;共上报42例次高警示药品ME;ME内容排名前3位为用量、给药途径及数量;引发ME的因素排名前3位为疲劳、知识欠缺及培训不足。结论:我院有必要建立健全的ME报告体系,减少ME发生率,提高患者用药安全。Objective:To analyze the specific content in the reports of medication errors(ME) in Huainan First Peaple’s Hospital(hereinafter referred to as our hospital) and prevent the occurrence of potential ME.Methods:The ME reports of our hospital from November 2016 to February 2019 were collected.The classification and distribution of ME,the ME involved drugs,the ME of high alert drugs,the classification of ME error content and the error factors of ME were analyzed retrospectively by the clinical pharmacist.Results:A total of 223 ME cases were reported in our hospital.According to the classification of errors,level B accounts for 67.26%,level C accounts for 17.04%,level D accounts for 11.21%,level E accounts for 2.24%,level F accounts for 2.24%.Level A,G,H,I were not reported.A total of 124 drugs are involved in ME,among which the top three are 0.9% sodium chloride injection,5% glucose injection and levofloxacin lactate dispersion tablets,and a total of 42 case-times of high alert drug ME were reported.The top three error contents of ME are dosage,administration route and quantity.The top three error factors of ME are fatigue,lack of knowledge and lack of training.Conclusion:According to the results of the content analysis of 223 ME cases,it is necessary for our hospital to establish a sound ME reporting system to reduce the incidence of ME and improve the drug safety in patients.

关 键 词：用药错误 高警示药品 用药安全 

分 类 号：R95[医药卫生—药学]