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目的通过对我院提高药品安全管理措施实施后用药错误(ME)报告的相关数据,探讨如何提高ME上报数量、降低ME发生比例、完善ME监测报告工作。方法收集我院2014年上报的药物异常事件处理报告单并进行分析,包括ME发生的环节类型、分类、引发因素和引发及发现ME的人数构成比。结果技术和类型错误中排在前三位的是处方开具与传递、给药与监测、药品调剂与分发,分别占61.3%、30.3%、7.6%。错误内容分析前三位分别是:品种错误(占39.7%)、用量错误(占33.9%)、用法错误(占10.8%)。引发因素中药品因素所占比例最高为40.5%,其次为人员因素占35.1%,再次为环境因素占20.6%。引发人员排在前三位的是医师、护士、药师,分别占引发人员的62.7%、22.7%、1.4%。发现人员中药师比例最高占88.4%。结论用药错误应该引起医疗机构的重视;药师是防止ME发生的关键力量。
Objective To explore how to increase the number of ME reports, reduce the proportion of MEs, and improve the ME monitoring report by referring to the data of ME reports after the implementation of drug safety management measures in our hospital. Methods The reports of handling anomalies of drugs reported in our hospital in 2014 were collected and analyzed, including the type, classification, triggering factors and the composition ratio of the number of patients initiating and finding ME. Results The top three technical and typological errors were prescription and delivery, administration and monitoring, and drug dispensing and distribution, accounting for 61.3%, 30.3% and 7.6% respectively. Error analysis of the top three were: breed error (39.7%), the amount of error (33.9%), usage errors (10.8%). In the trigger factor, the highest proportion of Chinese medicine factor was 40.5%, followed by 35.1% of personnel factor and again 20.6% of environmental factor. The top three triggers were physicians, nurses and pharmacists, accounting for 62.7%, 22.7% and 1.4% of initiators respectively. The highest proportion of Chinese medicine practitioners found was 88.4%. Conclusion The medical errors should be taken seriously by the medical institutions. The pharmacists are the key force to prevent the occurrence of ME.