摘要
目的分析处方环节用药错误的临床特点,为制定用药错误干预措施提供参考。方法收集2017年我院3 345例处方环节用药错误的记录数据,按季度进行柏拉图分析,制定干预措施,并对其干预效果进行评价。结果处方环节用药错误主要责任人为医生(88. 34%),报告人主要为临床药师(71. 39%)和药局审方药师(27. 83%);用药错误中以C级用药错误为主(占71. 18%),用药错误主要相关药品依次为神经系统用药、调节水电解质及酸碱平衡的药物及糖类注射液、心血管系统用药、营养药、消化系统用药;主要用药错误类型为药物选择错误、药物剂量/数量错误、给药浓度错误、遗漏错误、处方权限错误、给药频次错误;用药错误主要引发因素为医生因素、信息系统因素、患者因素、药品因素。结论通过建立实时审核干预和事后点评、分析、反馈标准化流程,完善信息化建设管理,加强教育与培训,可有效防控多数类型处方环节用药错误,但药物选择错误涉及影响因素复杂,干预措施短期难见成效。
Objective To study the clinical characteristics of medication errors in prescriptions,and provide references for formulating intervention measures for medication errors.Methods The records of 3 345 cases of medication errors in prescriptions of our hospital in 2017 were analyzed quarterly by Platon;the intervention measures were formulated;the effect of intervention was evaluated.Results The doctors are mainly responsible for medication errors in the prescriptions(88.34%),and the reporters were mainly clinical pharmacists(71.39%)and supervising pharmacists(27.83%).Most medication errors were evaluated as grade C(71.18%).Most medication errors occurred in the drugs used for nervous system,water-saving electrolytes,drug for acid and alkali balance,sugar injections,cardiovascular system medicine,nutrition medicine and digestive system medication.The main types of medication errors included errors of drug selection,drug dose/quantity,drug concentration,o mission,prescription authority and medication frequency.The main causes of medication errors included factors of doctors,information system,patients and drugs.Conclusion Most types of medication errors can be controlled by establishing standardized procedures for real-time medical advice auditing,intervention,post evaluation,analysis and feedback,improving informatization construction and management,and strengthening education and training;however,the drug selection error involves complex factors,and the intervention measures are not effective in the short term.
作者
王雨
韩佳容
陈超
WANG Yu;HAN Jia-rong;CHEN Chao(Department of Pharmacy,Liaoning Provincial People's Hospital,Shenyang 110016,China)
出处
《实用药物与临床》
CAS
2019年第1期97-102,共6页
Practical Pharmacy and Clinical Remedies
关键词
处方
用药错误
干预
Prescription
Medication error
Intervention
