甲氨蝶呤用药错误案例解析
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摘要
通过对1例甲氨喋呤用药错误案例的回顾,从用药错误产生的环节、归属的类型、用药错误分级、发生用药错误的危险因素等角度进行分析。并从技术和管理两个层面提出改进策略,提出可通过信息系统支持、加强制度落实、加强员工培训、营造安全文化等方面防范用药错误的发生。
Through a case report of misuse of methotrexate,the links of misuse,type,classification and risk factors of medication errors were discussed.From two aspects of technical and management,the improvement strategy was put forward to prevent medication error which included information system support,strengthening the system implement,staff training and creating a safety culture.
Through a case report of misuse of methotrexate,the links of misuse,type,classification and risk factors of medication errors were discussed.From two aspects of technical and management,the improvement strategy was put forward to prevent medication error which included information system support,strengthening the system implement,staff training and creating a safety culture.
引文
[1]中华医学会风湿病学分会.2018中国类风湿关节炎诊疗指南[J].中华内科杂志,2018,57(4):242-251.
[2]Moisa A,Fritz P,Benz D,et al.Iatrogenically-related,fatal methotrexate intoxication:A series of four cases[J].Forensic Science International,2006,156(2-3):154-157.
[3]Souza C F,Suarez O M,Silva TF,et al.Ulcerations due to methotrexate toxicity in a psoriasis patient[J].Anais Brasileiros de Dermatologia,2016,91(3):375-377.
[4]Arnet I,Bernhardt V,Hersberger K E.Case report methotrexate intoxication:the pharmaceutical care process reveals a critical error[J].J Clin Pharm Ther,2012,37:242-244.
[5]Shastay A.Severe harm and death associated with errors and drug interactions involving low-dose methotrexate[J].Home Healthc Now,2017,35(9):519-522.
[6]张青霞,闫素英,李晓玲,等.全国临床安全用药监测网2012-2017年甲氨蝶呤片用药错误报告分析[J].药物不良反应杂志,2018,20(3):187-192.
[7]中国医药教育协会高警示药品管理专业委员会,中国药学会医院药学专业委员会,中国药理学会药源性疾病学专业委员会.中国高警示药品临床使用与管理专家共识(2017)[J].药物不良反应杂志,2017,19(6):409-413.
[8]合理用药国际网络(INRUD)中国中心组临床安全用药组,中国药理学会药源性疾病学专业委员会,中国药学会医院药学专业委员会,等.中国用药错误管理专家共识[J].药物不良反应杂志,2014,16(6):321-326.
[9]吴亮,陈永荣.某医院新员工用药安全认知情况调查分析[J].安徽医药,2018,22(11):2268-2271.
[2]Moisa A,Fritz P,Benz D,et al.Iatrogenically-related,fatal methotrexate intoxication:A series of four cases[J].Forensic Science International,2006,156(2-3):154-157.
[3]Souza C F,Suarez O M,Silva TF,et al.Ulcerations due to methotrexate toxicity in a psoriasis patient[J].Anais Brasileiros de Dermatologia,2016,91(3):375-377.
[4]Arnet I,Bernhardt V,Hersberger K E.Case report methotrexate intoxication:the pharmaceutical care process reveals a critical error[J].J Clin Pharm Ther,2012,37:242-244.
[5]Shastay A.Severe harm and death associated with errors and drug interactions involving low-dose methotrexate[J].Home Healthc Now,2017,35(9):519-522.
[6]张青霞,闫素英,李晓玲,等.全国临床安全用药监测网2012-2017年甲氨蝶呤片用药错误报告分析[J].药物不良反应杂志,2018,20(3):187-192.
[7]中国医药教育协会高警示药品管理专业委员会,中国药学会医院药学专业委员会,中国药理学会药源性疾病学专业委员会.中国高警示药品临床使用与管理专家共识(2017)[J].药物不良反应杂志,2017,19(6):409-413.
[8]合理用药国际网络(INRUD)中国中心组临床安全用药组,中国药理学会药源性疾病学专业委员会,中国药学会医院药学专业委员会,等.中国用药错误管理专家共识[J].药物不良反应杂志,2014,16(6):321-326.
[9]吴亮,陈永荣.某医院新员工用药安全认知情况调查分析[J].安徽医药,2018,22(11):2268-2271.