OBJECTIVE: To probe into the reasons of input errors in electronic application form of blood concentration monitoring of phenobarbital and phenytoin sodium

so as to formulate specific improvement measures.METHODS: Root cause analysis was adopted to retrospectively analyze the root cause of input errors in electronic application form in blood concentration monitoring of phenobarbital and phenytoin sodium

two main reasons were found out: the Chinese names of phenobarbital and phenytoin sodium were look alike and sound-alike（ LASA） and in adjacent locations in computer

the clinician was too busy to check the electronic application form. Specific preventive measures were formulated respectively: separate the locations of phenobarbital and phenytoin sodium in computer system and training the clinicians for medical order check

the PDCA cycle was also introduced to improve step by step. RESULTS: After two rounds of specific PDCA improvement

the input errors in electronic application form of blood concentration monitoring of phenobarbital and phenytoin sodium had decreased from averagely 4 cases each month to 0. CONCLUSIONS: Clinicians should be aware of possible mix-ups errors of LASA drugs and adjacent locations in computer systems

to separate the locations of LASA drugs can significantly decrease the input errors in electronic application form of blood concentration monitoring.