住院药房常见用药差错原因与防范措施分析

目的 减少住院药房用药差错,提高药品调配质量,保证患者用药安全。方法 回顾性分析本院住院药房2013-01~2013-12收集的91例用药差错,归纳分析差错类型和原因,找出容易出错的环节和药品,并制定防范措施。结果与结论 常见的用药差错分成五大类,如：药品发错（45.05%）、数量发错（24.18%）、混淆病区（16.48%）、遗漏差错（13.19%）、质量差错（1.10%）,其中药品发错主要表现为发错药品品种（通常为外观或发音相似的药品）;发错名称相同药品的不同规格、不同厂家、不同剂型等。造成用药差错的主要原因有药品因素、药师因素、流程因素、配送工人因素以及环境因素,可通过科学合理地摆放药品、设计醒目标识、标准化工作流程、改进工作模式、合理调整药房区间布局、加强业务学习、合理排班等措施进行防范,以减少用药差错。

Analysis of Reasons and Precautionary Measures for Common Medication Errors in Inpatient Pharmacy

Objective To reduce medication errors and improve the quality of dispensing medicines, so as to ensure the patient medication safety in inpatient pharmacy. Methods Ninety-one cases of medication errors in inpatient pharmacy of the hospital from January 2013 to December 2013 were retrospective analyzed. The error types and reasons were summarized and analyzed. The error-prone procedures and medicines were identified, and precautionary measures were developed. Results ＆Conclusions Common medication errors were divided into 5 categories： dispensing the wrong medicine （accounting for 45.05% ）, dispensing the wrong quantity （accounting for 24.18%）, dispensing medicine for the wrong ward （ accounting for 16.48%）, omission （ i.e. failure to dispense） （ accounting for 13.19%）, and dispensing a medicine of inferior quality （accounting for 1.10%）. Dispensing the wrong medicine mainly includes dispensing the sound-alike and look-alike drugs, and dispensing the wrong drug strength, the wrong manufacturer, or the wrong dosage form, etc. The main factors that contribute to the medication errors include medication, pharmacist, procedure, distribution worker, and environment. The medication errors of inpatient pharmacy can be reduced by arranging medicines scientifically and rationally, designing eye-catching logo for indication, standardizing work process, improving working mode, rationally adjusting the layout of the pharmacy section, strengthening the career and technical education, more reasonable scheduling system, etc.