69例精神科用药错误报告分析

中国药物警戒 ›› 2017, Vol. 14 ›› Issue (1): 54-58.

69例精神科用药错误报告分析

庄红艳, 郝红兵, 刘珊珊, 果伟, 马辛^*, 李华维, 池伟, 张红玉

首都医科大学附属北京安定医院,北京 100088

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:庄红艳,女,硕士,主管药师,精神科临床药学。
基金资助:
北京市科技计划项目（Z151100004015180）; 北京市医院管理局临床医学发展专项经费资助（ZYLX201403）; 北京安定医院人才培养项目（YR-G201508）

Analysis of Psychiatric Medication Error Reports of 69 Cases

ZHUANG, Hong-yan, HAO Hong-bing, LIU Shan-shan, GUO Wei, MA Xin^*, LI Hua-wei, CHI Wei, ZHANG Hong-yu

Beijing Anding Hospital Affiliated to Capital Medical University, Beijing 100088, China

Received:2017-02-16 Revised:2017-02-16 Online:2017-01-20 Published:2017-02-16
Contact: 马辛,女,本科,主任医师,精神专科医院管理。E-mail: bjadyylcyxz@126.com

摘要/Abstract

摘要： 目的探讨我院常见用药错误（ME）的现状及特点,为临床安全用药提供参考。方法采用回顾性分析方法,对2011-2015年我院上报的69例ME报表,按患者的一般情况、差错类别分级、引发差错因素、差错内容、差错人员职位等主要方面用Excel表进行统计,并对差错类别分级、差错因素、差错内容、差错人员职位等方面进行汇总分析。A级ME为差错隐患,B、C、D为未对患者造成伤害的轻型ME,E、F、G、H、I级为对患者造成伤害甚至导致死亡的严重型ME。结果69例ME患者中,男性29例,女性40例;年龄最小15岁,最大82岁,平均年龄41.61岁;差错药品发给患者的占50.72%;患者使用了差错药品的占21.74%;差错类别分级中B、C类差错较多,97.11%为对患者无明显伤害;差错因素中,处方错误最多,占65.22%;在差错的具体内容中,药品用量错误发生率最高,占28.99%;引发差错的人员职位中,护士数量为0,绝大多数为医师、药师。结论我院ME中绝大多数未给患者带来伤害,但潜在危险因素较多,给患者用药安全带来隐患。应加强用药错误的管理,使医生、护士、药师、信息人员都加入到用药错误监测中来,最大限度地减少ME的发生。

关键词: 精神科, 用药错误, 管理, 合理用药

Abstract: ObjectiveTo discuss the current situation and characteristics of the common medication errors of our hospital and provide reference for clinical safe drug use. Methods69 cases of medication errors reported in the five years of 2011~2015 in our hospital were analyzed. EXCEL table was used to summarize the data, according to the main aspects of the patients' general conditions, error category classifications, the factors that cause error, the content of the error and the position of the person who caused errors.We also summarized and analyzed the error category classifications, error factors, the content of the error and the position of the person who cause errors. Category A is potential error. Category B, C, and D are mild ME which didn’t do harm to patients. Category E, F, G, H and I are severe ME which cause harm to patients even to death. ResultsThere were 29 male and 40 female patients with medication errors in the 69 cases. The youngest patient was at the age of 15, the oldest 82 years old. The mean age of the patients was 41.61. 50.72% of the error drugs had dispensed to the patients. 21.74% of the patients had used the wrong drug. There were more grade B and C errors in the error category classification. In the extent of damage to patients, 97.11% was of no obvious injury, the prescription error was of the most in the factors that cause errors, accounting for 65.22%.In the specific content of the error. The rate of drug dosage error was the highest, accounting for 28.99%. In the aspect of the positions of who had caused errors, the number of nurses was 0, the vast majority were physicians and pharmacists. ConclusionThe vast majority medication errors of our hospital didn’t bring harm to patients, but many potential risk factors brought hidden trouble to patients on medication safety. We should strengthen the management of medication errors, encouraging the doctors, nurses, pharmacists and information personnel monitoring the medication errors to minimize the occurrence of medication errors.

Key words: psychiatry, medication error, management, rational use of drugs

中图分类号:

R969.3

庄红艳, 郝红兵, 刘珊珊, 果伟, 马辛, 李华维, 池伟, 张红玉. 69例精神科用药错误报告分析[J]. 中国药物警戒, 2017, 14(1): 54-58.

ZHUANG, Hong-yan, HAO Hong-bing, LIU Shan-shan, GUO Wei, MA Xin, LI Hua-wei, CHI Wei, ZHANG Hong-yu. Analysis of Psychiatric Medication Error Reports of 69 Cases[J]. Chinese Journal of Pharmacovigilance, 2017, 14(1): 54-58.

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