医院用药差错的系统分析与对策

目的:分析某省级三甲医院药疗实践中出现的用药差错情况,提高药学服务水平和药师调剂质量,减少医疗安全隐患,促进医院医疗质量提升。方法:汇总该院2012年9月1日-2013年8月31日出现的用药差错,采用美国国家用药差错报告和预防协调委员会(NCC-MERP)用药差错分级方法进行汇总,分析用药差错产生的原因,提出适当的防范措施和对策。结果:本研究共收集332例用药差错,占总调剂总量的0.11‰。按照不同分类方法汇总分析发现:98.2%(326)的差错未造成患者伤害;内部差错与出门差错比例为291:41;差错发生率最高的为药师调配数量差错,占到33.4%;鱼骨图分析得出人、事、物为造成调配数量差错的三个主要原因。结论:用药差错是客观存在的,医院应当在建立现代的非惩罚性用药差错事件上报制度上,采取鼓励措施促使医务人员积极自愿上报用药差错事件,并利用质量管理工具全面分析和防范用药差错。

Systematic analysis and countermeasures for hospital medication errors

OBJECTIVE To analyze the medication errors in a first-class provincial hospital to improve service level of pharmacy and preparation quality of pharmacist, reduce hidden dangers of medical security, and promote improvement of medical quality in hospitals. METHODS Medication errors between September 1^st, 2012 and August 31^st, 2013 were summarized in the hospital. All the medication errors were categorized and analyzed according to the method development by National Coordinating Council for Medication Error Reporting and Prevention (NCC-MERP) to analyze the reasons for medication errors, and propose proper countermeasures. RESULTS A total of 332 medication errors were collected, accounted for 0.11% of total number of dispensation . According to the different categorizing methods, 98.2% (326) had not caused harm to patients. The ratio of internal error and external error was 291:41. Dispensing error by pharmacist accounted the highest proportion, accounting for 33.4%. By fish bone analysis, people, event and item were the three major reasons for dispensing errors. CONCLUSION Medication errors are objective. The hospital should establish modern non-punitive error event reporting system, adopt encouraging measures to promote medical staff to voluntarily report medication errors, and utilize quality administration tolls to comprehensively analyze and prevent medication errors.