我院门诊处方中26例高危药品用药错误的原因分析及防范措施
发布时间：2019-06-25 09:05
【摘要】：目的:为减少乃至杜绝门诊高危药品的用药错误提供参考。方法:收集2013-2014年我院门诊处方点评中发现的高危药品用药错误,对用药错误的类型、差错级别和引发差错的因素等进行回顾性分析。结果:2年共点评处方670 997张,发现用药错误501例,其中高危药品的用药错误26例,包括胰岛素给药途径错误7例、口服降糖药重复用药和给药剂量错误各1例、阿片类药品和非甾体抗炎药重复用药6例、氨酚待因适应证错误2例、葡萄糖注射液规格错误和适应证错误各1例、利多卡因给药途径错误2例、甲氨蝶呤给药频率错误2例、地高辛给药剂量错误2例、华法林给药剂量错误1例。医师处方错误,经药师审核发现错误并拒绝调配的18例,占69.2%;医师处方错误而药师未发现的8例,占30.8%。结论:门诊高危药品的用药错误主要发生在医师处方环节,主要原因为电子医嘱系统没有实行强制和约束策略。提高门诊高危药品安全用药水平需要找到差错环节并采取靶向性安全用药方案。
[Abstract]:Objective: to provide reference for reducing and even eliminating the error of drug use in outpatient high risk drugs. Methods: the errors of high risk drugs found in the evaluation of outpatient prescriptions in our hospital from 2013 to 2014 were collected, and the types of drug errors, the level of errors and the factors causing errors were analyzed retrospectively. the types of drug errors, the levels of errors and the factors causing errors were analyzed retrospectively. Results: a total of 670997 prescriptions were reviewed in 2 years. 501 cases of drug errors were found, including 26 cases of high risk drugs, including 7 cases of insulin administration error, 1 case of oral hypoglycemic drug reuse and 1 case of oral hypoglycemic drug dose error, 6 cases of opioid and non-steroidal anti-inflammatory drugs, 2 cases of aminophenol codeine indication error, 1 case of glucose injection specification error and 1 case of indication error. There were 2 cases of wrong administration route of lidocaine, 2 cases of methotrexate administration frequency error, 2 cases of digoxin administration dose error and 1 case of warfarin administration dose error. 18 cases (69.2%) were found wrong by pharmacists and 8 cases (30.8%) were not found by pharmacists. Conclusion: the drug error of high risk drugs in outpatient department mainly occurs in the link of doctor's prescription, the main reason is that the electronic doctor's order system does not carry out the compulsory and restraint strategy. To improve the level of safe drug use in outpatient department, it is necessary to find the wrong link and adopt the targeted safe drug use scheme.
【作者单位】： 北京大学首钢医院药剂科;
【分类号】：R969.3
[Abstract]:Objective: to provide reference for reducing and even eliminating the error of drug use in outpatient high risk drugs. Methods: the errors of high risk drugs found in the evaluation of outpatient prescriptions in our hospital from 2013 to 2014 were collected, and the types of drug errors, the level of errors and the factors causing errors were analyzed retrospectively. the types of drug errors, the levels of errors and the factors causing errors were analyzed retrospectively. Results: a total of 670997 prescriptions were reviewed in 2 years. 501 cases of drug errors were found, including 26 cases of high risk drugs, including 7 cases of insulin administration error, 1 case of oral hypoglycemic drug reuse and 1 case of oral hypoglycemic drug dose error, 6 cases of opioid and non-steroidal anti-inflammatory drugs, 2 cases of aminophenol codeine indication error, 1 case of glucose injection specification error and 1 case of indication error. There were 2 cases of wrong administration route of lidocaine, 2 cases of methotrexate administration frequency error, 2 cases of digoxin administration dose error and 1 case of warfarin administration dose error. 18 cases (69.2%) were found wrong by pharmacists and 8 cases (30.8%) were not found by pharmacists. Conclusion: the drug error of high risk drugs in outpatient department mainly occurs in the link of doctor's prescription, the main reason is that the electronic doctor's order system does not carry out the compulsory and restraint strategy. To improve the level of safe drug use in outpatient department, it is necessary to find the wrong link and adopt the targeted safe drug use scheme.
【作者单位】： 北京大学首钢医院药剂科;
【分类号】：R969.3
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