糖尿病患者降糖药物用药错误情况分析  

Analysis of medication errors in antidiabetic drug use among diabetic patients

作　　者：蔡星宇 师佩兰 时照明 吴道爱 郭道华 苏君 CAI Xingyu;SHI Peilan;SHI Zhaoming;WU Daoai;GUO Daohua;SU Jun(School of Clinical Medicine,Bengbu Medical University,Anhui Province,Bengbu 233030,China;不详)

机构地区：[1]蚌埠医科大学临床医学院,安徽省蚌埠市233030 [2]蚌埠医科大学第一附属医院药剂科,安徽省蚌埠市233004 [3]蚌埠医科大学第一附属医院内分泌科,安徽省蚌埠市233004

出　　处：《临床合理用药》2025年第2期16-19,共4页Chinese Journal of Clinical Rational Drug Use

摘　　要：目的分析糖尿病患者降糖药物的用药错误(ME)发生情况,为制定防范措施提供参考。方法收集2017年7月—2023年7月蚌埠医科大学第一附属医院内分泌科药师上报至合理用药国际网络(INRUD)中国中心组临床安全用药监测网的降糖药物相关ME报告,共149例。分析患者的临床资料,统计胰岛素及口服降糖药物ME涉及的药品、错误内容、错误引发因素、发生场所及错误引发人员,并绘制帕累托图对ME内容和因素进行分析。结果设定时间段内降糖药物ME共149例,涉及口服降糖药76例(51.01%),胰岛素制剂73例(48.99%)。ME错误内容主要包括漏给药、用量及给药频次错误;造成ME的主要因素为疲劳和知识欠缺;发生ME场所在病房最多,共117例(78.52%);患者及家属是引发ME的主要人员(137/149,91.95%)。结论医护人员应针对糖尿病患者降糖药物ME的具体情况,加强个体化的用药宣教及指导,通过多种方式提高患者的用药认知水平及依从性,制定相应的防范措施,降低临床ME的发生率,提高用药的安全性和合理性。Objective To analyze the occurrence of medication errors(MEs)in antidiabetic drug use and provide a reference for the development of preventive measures.Methods A total of 149 ME reports related to antidiabetic drugs were collected from the Clinical Pharmacovigilance Network of the China Center for the International Network for Rational Use of Drugs(INRUD),which were reported by pharmacists in the endocrinology department of The First Affiliated Hospital of Bengbu Medical University from July 2017 to July 2023.The clinical data of these patients were analyzed,and the drugs involved in insulin and oral hypoglycemic agent MEs,the content of errors,the factors contributing to errors,the occurrence sites,and the individuals who caused the errors were statistically analyzed.Pareto charts were used to analyze the content and factors of MEs.Results Among the 149 MEs related to antidiabetic drugs during the specified time period,76 cases(51.01%)involved oral hypoglycemic agents,and 73 cases(48.99%)involved insulin preparations.The main types of MEs included missed doses,dosage errors,and errors in dosing frequency.Fatigue and lack of knowledge were the primary contributing factors to MEs.The ward was the most common site for MEs,accounting for 117 cases(78.52%).Patients and their families were the main individuals responsible for MEs,accounting for 137 out of 149 cases(91.95%).Conclusion Healthcare providers should strengthen individualized medication education and guidance for diabetic patients based on the specific MEs related to antidiabetic drugs.By employing various methods to enhance patients′knowledge and adherence to medication,healthcare providers can develop corresponding preventive measures to reduce the incidence of clinical MEs and improve the safety and rationality of medication use.

关 键 词：糖尿病 降糖药物 用药错误 

分 类 号：R969.3[医药卫生—药理学]