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