某肿瘤医院分院区用药错误分析和防范启示  

Analysis and prevention of medication errors in a cancer hospital

作　　者：齐婧雯 尹月[1] 王明辉[1] 张艳华[1] QI Jing-wen;YIN Yue;WANG Ming-hui(Key laboratory of Carcinogenesis and Translational Research(Ministry of Education/Beijing),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：《中国处方药》2022年第9期64-66,共3页Journal of China Prescription Drug

摘　　要：目的分析院区用药错误及其影响因素,促进临床用药安全。方法对院区药房及静脉药物配置中心(PIVAS)2018年1月~2019年12月的用药错误进行统计处理,分析差错发生的影响因素,制定干预措施。结果用药错误主要有医师因素和药师因素,2018年医师因素占比85.98%,药师因素占比14.02%,医师因素排在前三位的依次为不符合医保适应证146例(38.63%),诊断与用药不符107例(28.31%),给药剂量不适宜31例(8.20%);药师因素排在前三位的依次为数量错误26例(6.88%),多厂家错误10例(2.65%),品种错误7例(1.85%);2019年医师因素占比89.79%,药师因素占比10.21%,医师因素显示排在前三位的依次为诊断与用药不符175例(52.56%),不符合医保适应证42例(12.61%),给药剂量不适宜39例(11.71%);药师因素排在前三位的依次为数量错误22例(6.61%),多厂家错误5例(1.50%),漏摆药错误4例(1.20%)。用药错误的发生率在干预后由2018年的0.19%(378/206552)下降到2019年的0.17%(333/197571)。结论制定合理的干预措施,医师和药师建立良好的合作关系,可以在一定程度上减少用药错误的发生,保证临床用药的安全,有效提升医疗服务质量。Objective Analyze the medication errors and their influencing factors in the hospital to promote the safety of clinical medication.Methods The medication errors in the pharmacy of our hospital and PIVAS from January 2018 to December 2019 were statistically processed,the influencing factors of the errors were analyzed,and the intervention measures were formulated.Results Medication errors mainly include physician factors and pharmacist factors.In 2018,physician factors accounted for 85.98%,pharmacist factors accounted for 14.02%,and the top three physician factors were non-medical insurance indications accouted for 146 cases(38.63%),the diagnosis does not match the medication 107 cases(28.31%),the dose inappropriate 31 cases(8.20%);the top three pharmacist factors are the number error 26 cases(6.88%),and the multi-manufacturer error 10 cases(2.65%),variety error 7 cases(1.85%);In 2019,physician factors accounted for 89.79%,pharmacist factors accounted for 10.21%,and physician factors showed that the top three factors were diagnosis and medication discrepancies 175 cases(52.56%).Non-compliance with medical insurance indications 42 cases(12.61%),unsuitable dose 39 cases(11.71%);the top three pharmacist factors are the number error 22 cases(6.61%),and the multi-manufacturer error 5 cases(1.50%),missing medicine error 4 cases(1.20%).The incidence of medication errors dropped from 0.19%(378/206552)in 2018 to 0.17%(333/19771)in 2019 after the intervention.Conclusion The establishment of reasonable intervention measures and the establishment of a good cooperative relationship between physicians and pharmacists can reduce the occurrence of medication errors to a certain extent,ensure the safety of clinical medication,and effectively improve the quality of medical services.

关 键 词：用药错误 用药安全 影响因素 干预 

分 类 号：R95[医药卫生—药学]