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北京医院药学部国家老年医学中心中国医学科学院老年医学研究院
纸质出版日期:2020,
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[1]罗太敏,陈露露,尹美慧,金阳,梁晓丽,谭玲.828例用药错误分析及防范策略[J].中国医院用药评价与分析,2020,20(06):742-745.
LUO Taimin, CHEN Lulu, YIN Meihui, et al. Analysis of 828 Cases of Medication Errors and Preventive Strategies[J]. 2020,20(6):742-745.
[1]罗太敏,陈露露,尹美慧,金阳,梁晓丽,谭玲.828例用药错误分析及防范策略[J].中国医院用药评价与分析,2020,20(06):742-745. DOI: 10.14009/j.issn.1672-2124.2020.06.027.
LUO Taimin, CHEN Lulu, YIN Meihui, et al. Analysis of 828 Cases of Medication Errors and Preventive Strategies[J]. 2020,20(6):742-745. DOI: 10.14009/j.issn.1672-2124.2020.06.027.
目的:了解北京医院(以下简称"我院")用药错误(medication error
ME)的发生情况
探讨保障患者安全用药、防范错误的策略。方法:收集2016年1月至2019年9月我院上报的ME
采用回顾性分析方法
记录ME的分级、内容、引发因素、发现人员以及错误相关药品等内容。结果:共收集到828例ME
其中A级2例
B级811例
C级15例
无D级以上ME。ME内容统计中
药物用量错误发生率最高(187例次
占总例次数833例次的22. 45%)
其次为品种错误(170例次
占总例次数833例次的20. 41%)、重复给药错误(101例次
占总例次数833例次的12. 12%)。ME的引发因素中
技术不熟练引发的ME最多(255例次
占总例次数919例次的27. 75%)
其次为知识欠缺(241例次
占总例次数919例次的26. 22%)。828例ME中
引发ME的人员主要为医师(490例
占59. 18%);药师发现并上报的ME最多(564例
占68. 12%)。ME报告中涉及药物以心血管系统用药最多。结论:我院应加强医师和药师的专业技能培训
同时进一步优化医院信息化管理系统
以减少ME的发生
保障患者安全用药。
OBJECTIVE: To investigate the occurrence of medication errors( ME) in Beijing hospital( hereinafter referred to as "our hospital")
and explore strategies to ensure medication safety and prevent errors. METHODS: ME reported from Jan. 2016 to Sept. 2019 in our hospital were collected. Retrospective analysis was performed to record the categories
contents
triggers
discoverers
and error-related drugs of ME. RESULTS: Totally 828 cases of ME were collected
including 2 cases of category A
811 cases of category B
15 cases of category C
category D and above was not reported. In terms of the ME contents
the proportion of drug dosage error was the highest( 187 case-times
accounting for 22. 45% of the total 833 case-times)
followed by drug variety error( 170 case-times
accounting for20. 41% of the total 833 case-times) and the repeated medication error( 101 case-times
accounting for 12. 12% of the total 833 case-times). Among the triggers of ME
unskilled ME was the most common( 255 case-times
accounting for27. 75% of the total 919 case-times)
followed by lack of knowledge( 241 case-times
accounting for 26. 22% of the total 919 case-times). Of the 828 cases of ME
the main cause cases of ME was clinicians( 490 cases
59. 18%);pharmacists found and reported the most ME( 564 cases
68. 12%). Among of the ME reports
cardiovascular system drugs were the most frequently error. CONCLUSIONS: Our hospital should strengthen the professional skills training of clinicians and pharmacists
as well as further optimize the hospital information management system in order to reduce the occurrence of ME and ensure the safe medication for patients.
用药错误ME安全用药
Medication errorMEMedication safety
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