中成药处方调剂差错1132例分析

目的 降低门诊中药房的中成药差错,提高药师工作质量,保障患者用药安全。方法 逐一整理2014年1月至2015年11月北京世纪坛医院《中成药药品发药差错登记本》及《中成药药品调配差错登记本》中记载的用药(发药调配)差错案例,分析原因并提出改进措施。结果 2014年1月至2015年11月内共发生1 132件用药差错,其中2014年用药差错770件,2015年362件,2015年比2014年下降52.99%,总体分析该院用药差错呈下降趋势。其中,药品差错为主要差错共997件,主要体现为药品数量、剂型和名称相似差错等。药品差错的主要原因在于工作环境压力和调剂发药流程的漏洞,而医生处方差错和收费处差错的主要原因在于对药品信息的不熟悉和系统漏洞。相应的改进措施是:严格遵守调剂制度；优化操作流程；加强药品管理；提高药师的操作技能及责任心；差错经验分享。结论 药品差错是用药(发药调配)中成药差错的主要方面。回顾性分析真实差错案例,有助于发现工作环节的问题并改进,使患者用药安全得到保障,增加患者满意度。

Chinese patent medicine errors and its prevention in the pharmacy of Chinese medicine:an analysis of 1 132 cases

Objective To reduce the Chinese patent medicine errors (MEs) in the pharmacy of Chinese medicine and to improve the quality of pharmacist work.Methods The medication errors recorded in the book which was used to record the Chinese patent medicine dispensing errors from January 2014 to November 2015 were analyzed.We tried to find out the reasons for these cases and put forward corrective proposals.Results There are 1 132 ME cases with 770 cases in 2014 and 362 ones in 2015.However,there was a 52.99% drop in 2015 compared with 2014,which indicated the medication errors declined in recent years.Among them,errors of 997 cases were drug errors,including errors in drug quantity,dosage form and mistaken medicine name.The environment pressure and the imperfect dispensing process were the main reasons for drug errors,while the unfamiliarity with Chinese patent medicine and the computer system mistakes might be the common reasons for MEs in consulting room and toll house.The corresponding improving measures should include optimizing dispensing process,strengthening the drug management,improving the operation skill and responsibility of pharmacist and sharing experiences.Conclusions Drug errors and physician prescribing errors were the most important factors in ME.This paper analyzed the MEs from the retrospective view and found the problems in daily works,which were beneficial for ensuring the rational drug use and improving patient satisfaction.