全国临床安全用药监测网2015年5月至2022年6月胰岛素用药错误报告分析  

Analysis on reports of medication errors on insulin preparations in National Monitoring Network for Clinical Safe Medication from May 2015 to June 2022

作　　者：晏彦[1] 王雅葳[1] 曾艳[1] 闫素英[1] 王育琴[1] Yan Yan;Wang Yawei;Zeng Yan;Yan Suying;Wang Yuqing(Department of Pharmacy,Xuanwu Hospital,Capital Medical University,Beijing 100053,China)

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》2022年第11期564-570,共7页Adverse Drug Reactions Journal

基　　金：北京市科学技术委员会专项资助课题(D181100000218002)。

摘　　要：目的了解和分析胰岛素用药错误(ME)发生情况及其影响因素,为规范使用该类药物提供参考。方法收集全国临床安全用药监测网(监测网)2015年5月6日至2022年6月30日收到的胰岛素ME报告,对ME分级及涉及的药品、错误内容、引发和发现错误人员及引发因素进行分析。结果设定时间段内监测网收到我国26个省级行政区193家医院上报的胰岛素制剂ME报告2215例,涉及患者2215例;男性1345例(60.72%),女性870例(39.28%);年龄(52±4)岁,范围1~95岁;轻型ME 2182例(98.51%),严重ME 33例(1.49%);2215例ME涉及8类29个品种的胰岛素和2263例次错误内容,ME内容居前3位者依次为品种错误(40.70%,921例次)、相互作用/配伍错误(18.29%,414例次)和用量错误(9.06%,205例次)。2215例ME中,引发错误人员为医师、药师、患者/家属、护士和其他者分别占58.24%(1290例)、28.26%(626例)、6.5%(144例)、5.60%(124例)和1.40%(31例);2215例ME中1741例(78.60%)被发现并被拦截,发现人员中药师占75.70%(1318例),患者及家属占14.01%(244例),护士占7.76%(135例),医师占2.53%(44例)。引发错误的因素共3011例次,主要为知识欠缺(23.28%,701例次)、药名相似(19.36%,583例次)和疲劳(14.51%,437例次)等。结论胰岛素制剂相关ME的错误内容以品种、配伍和用量错误为主,主要引发人员为医师,发现并拦截错误者多为药师,引发错误的主要因素为知识欠缺、药名相似和疲劳。Objective To understand and analyze the occurrence of medication error(ME)on insulin preparations and its influencing factors and provide reference for the standard use of insulin prepara⁃tions.Methods The ME reports on insulin preparation⁃related MEs in the National Monitoring Network for Clinical Safe Medication(monitoring network)from May 6,2015 to June 30,2022,were collected and information of MEs including drugs involved,grading,error content,the persons who caused and found the errors,and the factors that triggered the errors were analyzed.Results During the set period,a total of 2215 ME reports from 193 hospitals in 26 provinces and municipalities in China were collected in the moni⁃toring network.A total of 2215 patients were involved,including 1345 males(60.72%)and 870 females(39.28%),aged from 1 to 95 years,with an average age of(52±4)years.Two thousand one hundred and eighty⁃two MEs(98.51%)were mild and 33(1.49%)were severe.The 2215 ME reports involved 8 classes and 29 kinds of insulin,and a total of 2263 times of ME content.The top 3 ME contents of insulin prepara⁃tions were variety errors(40.70%,921),interaction/compatibility errors(18.29%,414),and dosage errors(9.06%,205).Among the 2215 MEs,58.24%(1290 MEs)were triggered by physicians,28.26%(626 MEs)by pharmacists,6.5%(144 MEs)by patients and their families,5.6%(124 MEs)by nurses,and 1.40%(31 MEs)by others;1741 MEs(78.60%)were detected and intercepted in time,of which 75.70%(1318)were found by pharmacists,14.01%(244)by patients/family members,7.76%(135)by nurses,and 2.53%(44)by physicians.The main factors that caused MEs were lack of knowledge(23.28%,701),similar drug names(19.36%,583),fatigue(14.51%,437),etc.Conclusions The contents of insulin preparations⁃related MEs mainly include variety error,interaction/compatibility error,and dosage error.MEs are mainly caused by physicians and mostly discovered and intercepted by pharmacists.Lack of knowledge,similar drug names,and fatigue are the major factors causing MEs.

关 键 词：胰岛素 用药错误 安全管理 监测网络 

分 类 号：R95[医药卫生—药学]