静脉用药调配中心细胞毒性药物用药错误发生情况分析  

Analysis of medication errors of cytotoxic drugs in pharmacy intravenous admixture service

作　　者：张文思[1] 张艳华[1] 李雪梅[1] 韩靖霞 丁奕[1] Zhang Wensi;Zhang Yanhua;Li Xuemei;Han Jingxia;Ding Yi(Key Laboratory of Carcinogenesis and Translational Research(Ministry of Education/Beijing),Department of Pharmacy,Peking University Cancer Hospital&Institute,Beijing 100142,China)

机构地区：[1]北京大学肿瘤医院暨北京市肿瘤防治研究所药剂科,恶性肿瘤发病机制及转化研究教育部重点实验室,北京100142

出　　处：《药物不良反应杂志》2020年第11期613-618,共6页Adverse Drug Reactions Journal

摘　　要：目的探讨静脉用药调配中心(PIVAS)细胞毒性药物用药错误(ME)的发生情况。方法通过医院信息系统调取2016年1月至2019年12月北京大学肿瘤医院PIVAS所有含细胞毒性药物的处方,筛选出药师审核处方时发现的ME(定义为处方错误),并翻阅PIVAS"用药错误记录本"筛选出同时段PIVAS内部发生的ME(定义为调配错误),对所有细胞毒性药物相关ME的分级、分类、发生环节、引发人员、错误内容和涉及的药物进行描述性分析。另将在PIVAS未被发现而传递至下一环节的ME定义为出门错误。结果设定时段我院PIVAS共收到细胞毒性药物处方347 367例,发现1 080例ME,ME发生率为0.31%。1 080例ME均为未造成患者伤害的B级错误,其中处方错误841例(77.87%),调配错误239例(22.13%);调配错误中有5例未被拦截而导致出门错误,出门错误发生率为0.01‰(5/347 367)。错误内容排在前5位者分别为溶媒错误(63.15%,682/1 080)、处方不完整(11.67%,126/1 080)、数量错误(8.80%,95/1 080)、用量错误(6.11%,66/1 080)和静脉给药方法错误(4.35%,47/1 080)。1 080例ME共涉及细胞毒性药物32种,排名前5位者依次为紫杉醇(23.24%,251/1 080)、氟尿嘧啶(12.59%,136/1 080)、多柔比星(6.39%,69/1 080)、顺铂(5.46%,59/1 080)和依托泊苷(5.37%,58/1 080)。结论我院PIVAS细胞毒性药物ME发生率为0.31%,均为B级错误。ME分类主要为处方错误,内容主要为溶媒错误,涉及的药物主要为紫杉醇、氟尿嘧啶、多柔比星、顺铂和依托泊苷。Objective To explore the occurrence of medication errors(MEs)involving cytotoxic drugs in pharmacy intravenous admixture service(PIVAS).Methods All the prescriptions containing cytotoxic drugs from January 2016 to December 2019 in PIVAS in Peking University Cancer Hospital were collected using the hospital information system.ME records found by pharmacists during the prescription review were screened out(defined as prescription error)and"the medication error record book"was searched to screen out MEs in PIVAS(defined as admixture errors)in the same period.Descriptive analysis was conducted on the grade,classification,links in which the MEs occurred,people who triggered,ME content,and the involved cytotoxic drugs of these MEs.In addition,the MEs that were not found in PIVAS but passed to the next link were defined as out-door errors.Results A total of 347367 prescriptions involving cytotoxic drugs were received in PIVAS in our hospital during the study period,in which 1080 MEs were found,and the incidence of ME was 0.31%.The 1080 MEs were all grade B errors that did not cause patient harm,of which 841(77.87%)were prescription errors and 239(22.13%)were admixture errors.Five MEs were not intercepted and led to out-door errors and the incidence of out-door errors was 0.01%o(5/347367).The top 5 ME contents were wrong solvent(63.15%,682/1080),incomplete prescription(11.67%,126/1080),wrong number(8.80%,95/1080),wrong dose(6.11%,66/1080),and wrong method in intravenous administration(4.35%,47/1080).A total of 32 cytotoxic drugs were involved in 1080 MEs and the top 5 were paclitaxels(23.24%,251/1080),fluorouracil(12.59%,136/1080),doxorubicin(6.39%,69/1080),cisplatin(5.46%,59/1080),and etoposide(5.37%,58/1080).Conclusions The incidence of ME was 0.31%in P1VAS in our hospital,all of which were grade B errors.The errors mainly were prescription errors,the main contents were wrong solvent,and the main drugs involved were paclitaxels,fluorouracil,doxorubicin,cisplatin,and etoposide.

关 键 词：用药错误 抗肿瘤药 患者安全 静脉用药集中调配中心 

分 类 号：R95[医药卫生—药学]