中国药物警戒 ›› 2022, Vol. 19 ›› Issue (11): 1242-1245.
DOI: 10.19803/j.1672-8629.20210548

• 安全与合理用药 • 上一篇    下一篇

胰岛素贮藏风险调查和典型用药错误案例分析与防范

张青霞1, 江永贤2△, 董月鑫3, 咸颖4, 王育琴1, 闫素英1,*   

  1. 1首都医科大学宣武医院药学部,国家老年疾病临床医学研究中心,北京100053;
    2四川省妇幼保健院药学部,成都 四川 610041;
    3北京市普仁医院药剂科,北京 100062;
    4北京市昌平区中西医结合医院药剂科,北京 102200
  • 收稿日期:2021-05-26 发布日期:2022-11-17
  • 通讯作者: *闫素英,女,本科,教授,主任药师,药事管理。E-mail:yansuying10@sina.cn
  • 作者简介:张青霞,女,硕士,副主任药师,用药安全管理及心血管慢病合理用药。△为并列第一作者。
  • 基金资助:
    国家重点研发计划（2020YFC2008305）; 北京市科学技术委员会“老年人多重用药管理模式的建立与临床应用研究”专项资助课题（D181100000218002）; 中国药学会科技开发中心科普课题（CMEI2021KPYJ00268）

Risk investigation of insulin storage and analysis and prevention of typical insulin-related medication errors

ZHANG Qingxia1, JIANG Yongxian2△, DONG Yuexin3, XIAN Ying4, WANG Yuqin1, YAN Suying1,*   

  1. 1Department of Pharmacy, Xuanwu Hospital, Capital Medical University, National Clinical Research Center for Geriatric Disease, Beijing 100053;
    2Department of Pharmacy, Sichuan Provincial Maternity and Child Health Care Hospital, Chengdu Sichuan, 610041;
    3Department of Pharmacy, Beijing Puren Hospital, Beijing 100062, China;
    4Department of Pharmacy, Beijing Hospital of Integrated Traditional Chinese and Western Medicine, Beijing 102200, China
  • Received:2021-05-26 Published:2022-11-17

PDF (PC)

232

摘要： 目的 对医务工作者和使用胰岛素患者的胰岛素贮藏问卷调查以及全国临床安全用药监测网（简称“监测网”）胰岛素贮藏用药错误案例报告的分析,了解胰岛素贮藏认知现状和胰岛素贮藏的风险点,并针对相关风险点提出防范措施,保障胰岛素的用药安全。方法 2020年7月18日至8月18日,通过问卷调查形式了解首都医科大学宣武医院的胰岛素使用最多科室（心脏内科和内分泌科）医生及护士、药师（门诊药房和住院药房）、使用胰岛素的患者（门诊和住院）对胰岛素贮藏的了解情况;收集监测网2012年9月22日至2020年9月30日来自全国的所有胰岛素贮藏相关用药错误报告,对错误报告涉及药品、错误分级、错误内容、错误环节及错误引发人员、错误因素等内容进行回顾性统计分析。结果 本研究共收集调查问卷93份,其中医务人员46份、患者47份。针对胰岛素开启前的贮藏问题,所有被调查者均知晓要在2~8℃冷藏贮藏,但均不知道冷藏时需要远离冰箱制冷元件;针对胰岛素开启后的正确贮藏问题,20名患者（42.55%）能够完全知晓,其比例高于医务人员16名（34.78%）。监测网胰岛素贮藏相关的用药错误报告16例,主要为B级11例（68.75%）、C级1例（6.25%）、D级2例（12.50%）和E级2例（12.50%）;16例胰岛素贮藏相关的用药错误中均与储藏温度和储藏位置相关,主要为应该冷藏而常温9例（56.25%）、应该远离冰箱制冷元件而未远离4例（25.00%）、应该冷藏而冷冻1例（6.25%）和应该常温而冷藏2例（12.50%）;16例胰岛素贮藏相关用药错误涉及的人员主要是患者及家属,共计7例（43.75%）。错误涉及的主要区域是患者家中（6例,37.50 %）和病区（4例,24.00%）。结论 医务人员和患者对胰岛素的贮藏知识误区较多,胰岛素贮藏不当影响血糖控制,所以应该从各个环节重视胰岛素的贮藏问题,从而保障胰岛素使用安全有效。

关键词: 胰岛素, 用药错误, 贮藏, 风险防范

Abstract: Objective To find out about the amount of knowledge of insulin storage and the risks related to insulin storage via a questionnaire survey, and to recommend precautions. Methods The amount of knowledge of insulin storage among doctors and nurses from departments where the usage of insulin was the largest, pharmacists and patients who used insulin in Xuanwu Hospital of Capital Medical University was investigated via a questionnaire between July 18 and August 18, 2020. All the reports about insulin storage-related medication errors (MEs) from September 22, 2012 to September 30,2020 were collected from the National Monitoring Network for Clinical Safe Medication (referred to as Monitoring Network). The errors involved drugs, classification of errors, types of errors, sites of errors, people who were responsible, and causes of errors. Results A total of 93 questionnaires were collected, including 46 from health care providers and 47 from patients. All the respondents knew that insulin had to be stored at 2~ 8℃ before opening, but they did not know that insulin needed to stay away from the freezer coil. As for proper storage of insulin after opening, 20 patients (42.55%) were fully aware of the problems, and the proportion was higher than that of health care givers (34.78%). There were 16 cases of medication errors related to insulin storage in the Monitoring Network, which were mainly grade B in 11 cases (68.75%), grade C in 1 case (6.25%), grade D in 2 cases (12.50%) and grade E in 2 cases (12.50%). Among these 16 cases, 9 (56.25%) stored insulin at room temperature, 4 (25.00%) kept insulin near the freezer coil, 2 (6.25%) froze insulin when it was to be in cool storage and 2 cases (12.50%) kept insulin in cool storage when it had to be frozen. The main subjects involved in MEs were patients and their families (43.75%). Conclusion Health care providers and patients have a number of myths about insulin storage, and improper insulin storage affects blood glucose control. Therefore, attention should be paid to insulin storage to ensure the safe and effective use of insulin.

Key words: insulin, medication errors, storage, risk prevention

中图分类号: