中国药物警戒 ›› 2015, Vol. 12 ›› Issue (2): 106-109.

• 医院药事管理与合理用药 • 上一篇    下一篇

345例用药错误原因分析及对策

陈宁,王婷,马莉   

  1. 北京积水潭医院药剂科，北京，100035
  • 收稿日期:2014-09-15 修回日期:2015-07-28 出版日期:2015-02-08 发布日期:2015-07-28
  • 作者简介:陈宁，女, 硕士，主管药师，医院药学。

Cause Analysis and Its Countermeasures of 345 Medication Errors

CHEN Ning，WANG Ting，MA Li   

  1. Department of Pharmacy, Beijing Jishuitan Hospital, Beijing 100035, China
  • Received:2014-09-15 Revised:2015-07-28 Online:2015-02-08 Published:2015-07-28

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摘要： 目的 分析用药错误（medication error，ME）发生的原因及特点，探讨如何减少用药错误的发生。方法 对2013年1月～2014年6月报告的345例用药错误进行回顾性分析，用根本原因分析法（root cause analysis，RCA）分析用药错误发生的原因。结果 A、B、C、D级ME分别占20.9%、76.2%、2.6%、0.3%，E、F、G、H、I级未有发生。ME的分类中药物品种错误比例最高，占35.1%，其次包括用量错误、溶媒和适应证错误等。ME的引发因素中药品名称相似是引发ME的最主要的原因，占24.9%。引发人员中医师、药师、护士、患者或家属占比分别为53.6%、35.1%、1.4%和0.3%。发现ME人员中药师占96.2%，在门诊药房和诊室有61.5%的ME发生。结论 应从更新设施、规范药品摆放、优化工作规范和流程、加强教育培训、建设非惩罚性安全用药文化等方面着手，不断改进或重新设计系统与过程，从而减少ME的发生。

关键词: 用药错误, 根本原因分析, 对策

Abstract: Objective To analyze the reasons and characteristics of medication errors(ME) occurrence in our hospital,discuss how to reduce the incidence of ME. Methods 345 cases of ME in our hospital from January 2013 to June 2014 were retrospectively analyzed by the root cause analysis (RCA). Results Proportion of ME category A, B, C, and D was respectively 20.9%,76.2%,2.6% and 0.3%. ME of category E、F、G、H and I have not been reported. The proportion of drug variety error was the highest, accounting for 35.1% followed by dosage error, indication error and solvent error. The top factor to trigger ME was similar drug name, which reached 24.9%. In terms of the persons that triggered ME, the proportion of doctors, pharmacists, nurses and patients or families was respectively 53.6%, 35.1%, 1.4% and 0.3%. 96.2% of ME were detected by pharmacists, 61.5% of ME occured in the outpatient pharmacy and consulting room. Conclusion It is advisable to update facilities, standardize drug placing, optimize work norms and procedures, strengthen the drug safety education and training, construct non-punitive safe drug use culture, allocate pharmacists manpower reasonably, pay attention to environment and equipment safety so as to continuously reduce the occurrence of ME.

Key words: medication errors(ME), root cause analysis, countermeasure

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