中国药物警戒 ›› 2017, Vol. 14 ›› Issue (1): 40-44.

• 综述 • 上一篇    下一篇

281例抗肿瘤药物用药错误分析

朱忱崔璨, 李晓玲*, 闫素英王育琴   

  1. 首都医科大学宣武医院药剂科,北京 100053
  • 收稿日期:2017-02-16 修回日期:2017-02-16 出版日期:2017-01-20 发布日期:2017-02-16
  • 作者简介:朱忱,女,在读硕士,临床药学。

Analysis of 281 Medication Errors of Antineoplastic Drugs

ZHU Chen, CUI Can, LI Xiao-ling*, YAN Su-ying, WANG Yu-qin   

  1. Xuanwu Hospital of Capital Medical University,Beijing 100053, China
  • Received:2017-02-16 Revised:2017-02-16 Online:2017-01-20 Published:2017-02-16
  • Contact: 李晓玲,女,博士,副主任药师,临床药学。E-mail：zhaozhao0104@126.com

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摘要： 目的了解我国临床安全用药监测网抗肿瘤用药错误（ME）报告现状和发生特点。方法收集2012年9月22日- 2015年12月31日报告的ME案例进行分析,项目包括ME分级、分类、涉及抗肿瘤药物种类、引发因素和引发及发现ME的人数及构成比。结果2012-2015年,共报告涉及抗肿瘤药物MEs281例。A、B、C、D、E、F、I级ME分别占13.17%（37例）、72.24%（203例）、11.03% （31例）、1.42%（4例）、1.42%（4例）、0.36%（1例）、0.36%（1例）,G、H级未有报告。出现频率最高的抗肿瘤药物是依托泊苷,其次是吉西他滨、卡铂、表柔比星、紫杉醇和环磷酰胺。ME占比最高的环节为医生医嘱开具环节（195例）,占69.4%,其次为药师（74例）,占26.33%,最后为护士（12例）,占4.27%。按ME的种类分,占比较高的是溶媒种类选择错误（18.86%）、溶媒量错误（16.37%）、剂量错误（14.23%）,均发生在医生医嘱开具环节。医生医嘱开具及药师调剂环节发生的MEs大多数可以在药品发出前被拦截,仅10.26%（20例）和21.62%（16例）累及患者;而在药品发出后,护士配药、给药环节则拦截率较低（33.33%）,大部分都累及患者（66.67%）。发现MEs的主要人群为药师（82.56%）,其次为护士（11.39%）。结论抗肿瘤药物从处方开具到患者使用,要经历多个环节,每一步的审查与拦截都对前一步程序起到把关作用。因此,医疗机构应重视抗肿瘤药物使用的ME防范,优化信息系统,制定严格的审核制度,提升医护药对ME的认知,切实将抗肿瘤药ME的发生降至最低,保障肿瘤患者用药安全。

关键词: 用药错误, 抗肿瘤药物

Abstract: ObjectiveTo understand the current status of medication error (ME) report of antineoplastic drug in China and improve the safety awareness of drug use. MethodsME cases reported from Sep. 22 nd, 2012 to Dec. 31st, 2015 were collected and analyzed in terms of category, classification, antineoplastic category and cause of ME. We also divided them by amount and proportion of persons who triggered or detected ME. ResultsFrom 2012 to 2015, 281 antineoplastic drug ME cases were reported. ME proportion of category A, B, C, D, E, F and I was 13.17% (37 cases), 72.24% (203 cases), 11.03% ( 31 cases), 1.42% ( 4 cases), 1.42%( 4 cases), 0.36% (1 case), and 0.36% (1 case), respectively. MEs of category G and H have not been reported. The most commonly involved antineoplastic drug was etoposide, followed by gemcitabine, carboplatin, epirubicin, paclitaxel, and cyclophosphamide. Doctors’ error was the highest proportion that reached 69.4% (332 errors), then pharmacists (74 cases), accounting for 26.33%, and finally the nurses (12 cases), 4.27%. The common error types were wrong solution, including types (18.86%) and volume (16.37%), and wrong dose (14.23%), which all occurred when doctors were prescribing. Most of MEs that occurred during prescription by doctors and preparation by pharmacists were detected before delivered to patients, only 10.26%(20 errors) and 21.62%(16 errors) reached. If the ME started at the nurses, it was more difficult to detect (33.33%). In terms of the persons who detected ME, the most were pharmacists (82.56%), and then nurses (11.39%). ConclusionFrom prescription to administration, antineoplastic drugs undergo multiple steps. It is very important to review and intercept before every step starts. Therefore, medical institutes should pay more attention to ME prevention of antineoplastic drugs, optimize the information system, formulate strict review system and enhance recognization of ME, in order to reduce ME incidence and ensure drug safety.

Key words: medication error, antineoplastic drug

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