191例用药差错的成因与对策

目的 分析用药差错的成因并寻求降低差错的对策.方法 针对药剂科用药差错登记、门诊用药咨询记录和护理部临床护理质量检查记录中的用药差错,按差错来源、出现差错人员的工作年限、差错后果或严重程度进行分类汇总.结果 191例用药差错来源于医师的106例,占55.50%;药师46例,占24.08%;护士31例,占16.23%;患者8例,占4.19%.按差错后果或严重程度分类,尚未出现错误97例,占50.79%;出现错误但未造成伤害88例,占46.07%;出现错误并造成伤害6例,占3.14%;未发生致死性错误.结论 建立良好的用药安全文化、及时分析用药差错的根源,并寻求解决办法、降低用药风险非常必要.

Causes and countermeasures of 191 cases of medication errors

Objective To analyze the causes of medication errors and seek countermeasures to reduce errors. Methods Registration of the medication errors in Department of Pharmacy, medication errors in outpatient drug coun- seling records and quality of care inspection records in accordance with the sources of error, personnel working years, error consequences or severity were analyzed. Results In 191 cases of medication errors, there were 106 cases （55.50%） from physicians, 46 cases （ 24. 08% ） from pharmacists, 31 cases （ 16. 23% ） from nurses and 8 cases （4. 19% ）from patients. According to the error consequences or severity classification, there were 97 cases （50. 79% ） with no error, 88 cases （46. 07 % ） of errors without harm and 6 cases （ 3. 14 % ） of errors with harm. There was non-fatal error. Conclusion To establish a good drug safety culture, analyze the root causes of medication errors in a timely manner and to seek solutions to reduce the risk of medication are necessary.