LI Ruilian, YUAN Sisi, WANG Yue, et al. Analysis of 394 Cases of Medication Errors in Women and Children. [J]. 21(4):497-500(2021) DOI: 10.14009/j.issn.1672-2124.2021.04.027.
Analysis of 394 Cases of Medication Errors in Women and Children
OBJECTIVE: To investigate the status of medication errors( ME) in women and children in Beijing Obstetrics and Gynecology Hospital
Capital Medical University( hereinafter referred to as "our hospital")
and to discuss the prevention strategies
so as to provide reference for improving medication safety in this field. METHODS:ME reports of our hospital reported on Chinese clinical drug safety monitoring network from 2016 to 2019 were collected and analyzed. Items included the triggering links
classification
involved drugs
error content
triggering factors and injury incidents. RESULTS: A total of 394 cases of ME were collected. ME reports of B
C
D
and E accounted for92. 39%( 364 cases)
3. 81%( 15 cases)
1. 78%( 7 cases) and 2. 03%( 8 cases)
respectively. There were no ME reports of A and F to I. Internal errors that did not reach the patient accounted for 90. 10%( 355 cases). Totally75. 00%( 6 cases) of ME reports of E were induced by the patients’ medication error. And 23. 60%( 93 cases) of ME were special population( including pregnant women
lactating women and infants). The top three drugs ranked by the number of ME reports were respectively Misoprostol tablets
Progesterone soft capsules and Dydrogesterone tablets. In terms of classifications of ME contents
the most errors in clinicians ’ prescriptions( medical order) were mainly dosage
route of administration and frequency of administration. The error of variety was the most in drug dispensing by pharmacists. Medication errors focused on dosage and administration techniques. The main factors of ME were imperfect information system
lack of knowledge and similar drug names. Drugs with similar appearance and sound mainly involved three categories of Chinese patent medicine for gynecology
estrogen and progesterone and topical drugs for gynecology. CONCLUSIONS: Attention should be paid to the prevention of ME in women and children
and relevant strategies should be developed to reduce the occurrence of ME.
关键词
用药错误妇幼专科用药安全防范策略
Keywords
Medication errorsSpecialty of women and childrenMedication safetyPrevention strategies
Analysis of Pre-Review and Intervention of 32 512 Medical Orders of Chinese Patent Medicine in All Wards of Beijing Friendship Hospital,Capital Medical University in 2020
Review and Analysis of 3000 Outpatient Prescriptions of Traditional Chinese Medicine Decoction Pieces
Investigation and Countermeasures on the Application of Oral Solid Preparation in Inpatients Over 60 Years Old
Reports of 221 Cases of Adverse Drug Reactions
Analysis of Adverse Drug Reactions in 925 Psychiatric Patients
Related Author
XUE Caiqiu
NI Jianteng
ZHANG Cong’en
ZHAO Kuijun
MA Zhijie
WANG Shuhua
WANG Shuhua
MA Zhijie
Related Institution
Dept.of TCM Pharmacy,Beijing Friendship Hospital,Capital Medical University
Dept.of Pharmacy,Beijing Friendship Hospital, Capital Medical University
Postdoctoral Research Station,China Academy of Chinese Medical Sciences
National Resource Center for Chinese Materia Medica,China Academy of Chinese Medical Sciences
Dept. of Pharmacy, the First Hospital of Jilin University