基于非惩罚制度下989例用药错误事件回顾性分析与风险防范
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摘要
目的:通过回顾性分析989例用药错误(medication error,简称ME)事件,明确用药错误的环节并提出针对性改进措施,为保障患者用药安全提供依据。方法:采用回顾性分析法对989例ME不良事件进行统计分析,包括ME分级、分类、错误环节、发生原因、事件责任主体及上报人员分布情况。结果:ME分级中,B级ME发生率最高占60.77%;ME主要发生在处方开具与转录环节占68.35%,其次是给药监测环节占22.14%;ME分类中用药剂量错误,用药途径错误,遗漏用药,用药频次错误,混淆药品错误居前五位,占比依次为23.96%,15.17%,14.36%,9.50%,6.88%;医护人员用药知识技能培训不足是导致ME的主要原因;ME的责任主体以医师为主占62.90%,其次是护士占30.03%;ME主要是由药师上报占64.71%。结论:医师处方错误是造成ME的首要原因,药师参与是保障用药安全的关键,提高医护人员的整体风险意识水平和综合素质是减少ME的重要途径,医院应进一步加强用药安全信息化建设及用药安全培训以保障患者用药安全。
OBJECTIVE Retrospective analysis of 989 medication errors(ME), identify the wrong part in mediction error, put forward the pertinent improvement measures and ensure medication safety. METHODS A retrospective analysis method was used to analyze 989 ME, including ME classification, type, wrong part, cause, ranks of the reporing staff. RESULTS The highest incidence of B-lass ME accounted for 60.77%; ME mainly occurred in prescription and transcription, acounted for 68.5%, Followed by medication delivery and monitoring accounted for 22. 4%: The top five ME were wrong dosage, wrong route, omission, wrong frequency and confusion accounted for 23.96%, 15.17% 14.36%, 9.50% 6.88% respectively. Lack of training in knowledge and skills was the main cause of ME. ME mainly caused by physicians accounted for 62.90%, followed by nurses accounted for 30.03%; 64.71% of the ME was mainly reprted by clinical pharmacists. CONCLUSION Prescription error is the leading cause of ME, clinical pharmacists' involvement was the key to ensuring medication safety. Hospital should enhance medication information construction and staff training on medication safety to further protect patients.
OBJECTIVE Retrospective analysis of 989 medication errors(ME), identify the wrong part in mediction error, put forward the pertinent improvement measures and ensure medication safety. METHODS A retrospective analysis method was used to analyze 989 ME, including ME classification, type, wrong part, cause, ranks of the reporing staff. RESULTS The highest incidence of B-lass ME accounted for 60.77%; ME mainly occurred in prescription and transcription, acounted for 68.5%, Followed by medication delivery and monitoring accounted for 22. 4%: The top five ME were wrong dosage, wrong route, omission, wrong frequency and confusion accounted for 23.96%, 15.17% 14.36%, 9.50% 6.88% respectively. Lack of training in knowledge and skills was the main cause of ME. ME mainly caused by physicians accounted for 62.90%, followed by nurses accounted for 30.03%; 64.71% of the ME was mainly reprted by clinical pharmacists. CONCLUSION Prescription error is the leading cause of ME, clinical pharmacists' involvement was the key to ensuring medication safety. Hospital should enhance medication information construction and staff training on medication safety to further protect patients.
引文
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[14] Wei LJ, Zhang ZL, Shi RF, et al. Investigation on medication errors and management status of different grade hospitals in Guangdong[J]. J Nurs(护理学杂志), 2016,31(10):5-8.
[15] Chen N, Wang T, MaL.Cause analysis and countermeasures of 345 cases of medication errors[J]. Chin J Pharmacovigilance(中国药物警戒) 2015,12(02):106-109.
[2] Cao Y, Luan HB, Sun N.Analysis and prevention of medication errors in a hospital in 2014[J].Capital Food Medicine(首都食品与医药),2016,23(10):68-69.
[3] Li LL, Jin R. Analysis of 106 cases of medication errors and risk prevention in our hospital[J].China Pharm (中国药房), 2016, 27(02):274-276.
[4] Liang HT, Shi XJ, Zhong MK.Medication errors and prevention[J]. Shanghai Med(上海医药), 2011,32(04):161-163.
[5] Huang QZ,Cai HJ. Analysis and prevention of medication errors in outpatient department of Pediatrics pharmacy [J].J Pediat Pharm(儿科药学杂志), 2012,18(10):62-64.
[6] Patient safety objectives of China Hospital Association (2017)[J].Chin Hosp(中国医院), 2017,21(01):81.
[7] Patient safety objectives of China Hospital Association (2017)[J].Chin Heal Quality MGT(中国卫生质量管理), 2017,24(02):13.
[8] American Society of Hospital Pharmacists.ASHP guidelines on preventing medication errors in hospitals[J] .Am J Hosp Pharm, 1993, 50(2):305-314.
[9] Shen JH, Chu YQ, Shi XH, et al.The role of the pharmacist in drug management and rational use of drugs in the operating room[J]. Chin Hosp Pharm J(中国医院药学杂志),2018,38(05):544-546.
[10] Xu YT. Investigation and analysis of nursing medication errors and countermeasures[J].World Latest Med Inf(世界最新医学信息文摘), 2015,15(77):157-161.
[11] Zhang FX, Ye FZ, Ye XZ. Exploration andthinking on the Management of Clinical Nursing Safety Drugs[J]. Chin Hosp(中国医院), 2010,14(02):74-76.
[12] Chen GY,Qian YF. Causes and improvement measures of hospital medication errors[J]. Chin J Pharm Econ(中国药物经济学), 2015,10(02):31-32.
[13] Zhou BB. Application of PDCA cycle management method in error monitoring of drugs in outpatient pharmacy[J].Her Med(医药导报), 2011,30(12):1677-1678.
[14] Wei LJ, Zhang ZL, Shi RF, et al. Investigation on medication errors and management status of different grade hospitals in Guangdong[J]. J Nurs(护理学杂志), 2016,31(10):5-8.
[15] Chen N, Wang T, MaL.Cause analysis and countermeasures of 345 cases of medication errors[J]. Chin J Pharmacovigilance(中国药物警戒) 2015,12(02):106-109.