全国临床安全用药监测网年度报告(2023年)  

Annual report of National Monitoring Network for Clinical Safe Medication(2023)

作　　者：张青霞[1] 李思妍 白向荣[1] 王子民[1] 闫素英[1] 王育琴[1] 合理用药国际网络中国中心组临床安全用药组 中国药理学会药源性疾病学专业委员会 药物不良反应杂志社 Zhang Qingxia;Li Siyan;Bai Xiangrong;Wang Zimin;Yan Suying;Wang Yuqin;Medication Safety Panel in China Core Group of International Network for the Rational Use of Drugs;Chinese Pharmacological Society Professional Committee of Drug‑induced Diseases;Adverse Drug Reactions Journal Agency(Department of Pharmacy,Xuanwu Hospital,Capital Medical University,Beijing 100053,China;School of Pharmacy,Capital Medical University,Beijing 100069,China;不详)

机构地区：[1]首都医科大学宣武医院药学部,北京100053 [2]首都医科大学药学院,北京100069 [3]不详

出　　处：《药物不良反应杂志》2024年第7期390-398,共9页Adverse Drug Reactions Journal

摘　　要：全国临床安全用药监测网2023年收到全国27个省级行政区439家医院的用药错误(ME)报告27742例。其中A级错误282例(1.02%),B级22452例(80.93%),C级4239例(15.28%),D级499例(1.80%),E级141例(0.51%),F级127例(0.46%),G级1例(<0.01%),I级1例(<0.01%),无H级病例发生。B~I级ME涉及的27460例患者中,男性15131例(55.10%),女性12329例(44.90%);年龄1 d~103岁,其中儿童(<18岁)3198例(11.65%),青中年人(≥18~<60岁)12576例(45.80%),老年人(≥60岁)11686例(42.56%)。错误内容居前3位者分别为品种(5880例次,20.97%)、用量(4668例次,16.65%)和给药频次(3184例次,11.35%)。导致患者伤害的严重ME(E~I级)涉及270例患者,男性140例(51.85%),女性130例(48.15%);年龄52 d~94岁,其中儿童31例(11.48%),青中年人91例(33.70%),老年人148例(54.82%);所涉药品在前3位者依次为头孢哌酮钠舒巴坦钠、二甲双胍和艾司唑仑,1例致死ME为误将复方荆芥熏洗剂口服所致。27460例B~I级ME中,引发错误人员主要为医师(19655例,71.58%)和药师(5688例,20.71%),少数为护士和患者/家属等。ME发生场所主要为门诊(10537例,38.37%),病房(8187例,29.81%),药房(6470例,23.56%);270例严重ME中121例(44.81%)发生场所是患者家中。错误发现人员居前3位者分别是药师20693例次(74.46%),患者/家属3240例次(11.66%),医师2214例次(7.97%)。引发错误因素居前3位者分别是知识欠缺(9382例次,28.35%)、疲劳(5974例次,18.05%)和培训不足(3831例次,11.58%)。针对2023年发生率较高和较严重的ME,以下风险需要加强防范,包括外用药误为内用、误服外包装、儿童用量剂量换算错误、特殊给药频次错误、肠内营养制剂和刺激性静脉制剂的滴注速度过快、蒙脱石散和其他药物相互作用、磷霉素钠导致高钠血症等。此外,加强频发严重ME及致死ME药物品种的管理,以及对患者的科普和安全用药教育等,有助于保障患者用药安全。In 2023,a total of 27742 cases of medication error(ME)from 439 hospitals in 27 pro⁃vincial administrative regions were collected in the National Monitoring Network for Clinical Safe Medica⁃tion.Among them,282(1.02%)were classified as grade A,22452(80.93%)as grade B,4239(15.28%)as grade C,499(1.80%)as grade D,141(0.51%)as grade E,127(0.46%)as grade F,1(<0.01%)as grade G,and 1(<0.01%)as grade I;no MEs of grade H occurred.Among the 27460 patients involved in MEs of grade B to I,15131(55.10%)were male and 12329(44.23%)were female;their ages were from 1 day to 103 years;3198(11.65%)were children(<18 years old),12576(45.80%)were young and middle⁃aged adults(≥18 to<60 years old),and 11686(42.56%)were elderly(≥60 years old).The top 3 contents of ME were wrong drug class(5880 cases,20.97%),wrong dosage(4668 cases,16.65%),and wrong administration frequency(3184 cases,11.35%).A total of 270 patients were involved in severe MEs(grade E⁃I),including 140(51.85%)males and 130(48.15%)females,aged from 52 days to 94 years,of which 31(11.48%)were children,91(33.70%)were young and middle⁃aged adults,and 148(54.82%)were elderly.The top 3 drugs involved were cefoperazone sodium and sulbactam sodium,metformin,and estazolam.One fatal ME was caused by mistakenly orally taking Fufang Jingjie for fumigation and washing.Among the 27460 grade B⁃I MEs,19655(71.58%)were triggered by physicians,5688(20.71%)by pharmacists,and few by nurses,patients and their family members,etc.These MEs mainly occurred in clinics(10537 cases,38.37%),in hospital wards(8187 cases,29.81%),and in pharmacies(6470 cases,23.56%).But among the 270 severe MEs,121(44.81%)occurred in the patient′s home.The top 3 persons who discovered the ME were phar⁃macists(20693 cases,74.46%),patients and their family members(3240 cases,11.66%),and physicians(2214 cases,7.97%).The top 3 factors causing ME were lack of related pharmacologic knowledge(9382 cases,28.3%),tiredness(5974 cases,18.05%),and insufficient training of medical workers(3831 cases,11.58%).In view

关 键 词：用药错误 患者安全 安全管理 年度报告 全国临床安全用药监测网 

分 类 号：R95[医药卫生—药学]