1例年龄4个月19 d、体重4.4 kg女婴在室间隔和房间隔缺损修补术后接受5%地高辛口服溶液0.9 ml（0.045 mg）口服、1次/12 h治疗，同时应用螺内酯、氢氯噻嗪和卡托普利。服药第6天行地高辛血药浓度检测，药师发现患儿地高辛血药物浓度>5.0 μg/L，立即到病房查看患儿。床旁心电监护仪示患儿心率减慢（80次/min）、心律不齐、Ⅲ度房室传导阻滞、完全性右束支传导阻滞和ST-T改变。诊断为地高辛中毒，立即停用地高辛。3 d后患儿血药浓度降至1.66 μg/L，心率及心电图恢复正常。经复习患儿用药信息，诊断为地高辛超剂量用药和药物相互作用导致的地高辛中毒事件。藉由这起事件，对2017年1月至2019年5月全院住院患儿地高辛使用情况进行了调查。323例患儿中，14例（4.3%）地高辛超剂量；235例（72.8%）治疗时间>5 d，但血药浓度送检率仅为12.8%（30/235）；67.5%（240/323）的患儿并用了与地高辛有相互作用或可能增加治疗风险的药物。经风险因素分析提出优化医嘱审核系统、提高地高辛血药浓度监测率和加强培训等改进措施并达成院内专家共识。改进措施实施后的2020年1至6月全院共47例患儿服用地高辛治疗，无一例超剂量用药，地高辛血药浓度监测率提高到45.2%（19/42）。“,”A 4-month and 19-day-old girl with a body weight of 4.4 kg was treated with 5% digoxin oral solution 0.9 ml (0.045 mg) once per 12 hours after repair of ventricular septal and atrial septal defects. Spironolactone, hydrochlorothiazide, and captopril were given at the same time. The blood concentration of digoxin was detected on the 6th day of medication, and the pharmacist found that it was more than 5.0 μg/L, and immediately went to the ward to see the child. The bedside electrocardiograph showed that the baby girl had reduced heart rate (80 beats/min), arrhythmia, third-degree atrioventricular block, complete right bundle-branch block, and ST-T changes. Digoxin poisoning was diagnosed and digoxin was immediately discontinued. Three days later, the blood concentration of digoxin decreased to 1.66 μg/L, and her heart rate and electrocardiograph returned to normal. By reviewing the medication information of the baby, a digoxin poisoning event due to overdose of digoxin and drug interactions was diagnosed. Due to the event, the use of digoxin in hospitalized children in the whole hospital from January 2017 to May 2019 was investigated. Among 323 children, 14 children (4.3%) overdosed with digoxin; 235 children (72.8%) were treated with digoxin for more than 5 days, but the detection rate of blood concentration was only 12.8% (30/235); 67.5% children (240/323) were prescribed drugs that might interact with digoxin or increase the risk in digoxin treatment. Through the analysis of risk factors, improvement measures such as optimizing medical order audit system, increasing the monitoring rate of digoxin blood concentration, and strengthening training were put forward, and an expert consensus in the hospital was reached. After implementation of the improvement measures, a total of 47 children were prescribed digoxin in the whole hospital from January to June, 2020, none of them were given overdose of digoxin, and the monitoring rate of digoxin blood concentration was increased to 40.4% (19/47).