药物不良反应杂志
藥物不良反應雜誌
약물불량반응잡지
ADVERSE DRUG REACTIONS JOURNAL
2013年
4期
207-210
,共4页
白杨%代姗姗%孔磊%黎红梅%孙瑞芳
白楊%代姍姍%孔磊%黎紅梅%孫瑞芳
백양%대산산%공뢰%려홍매%손서방
用药错误%监测,药物%门诊医疗
用藥錯誤%鑑測,藥物%門診醫療
용약착오%감측,약물%문진의료
Medication errors%Monitoring,drug%Ambulatory care
目的 分析门诊药房药品调剂差错发生情况及改进方向. 方法 收集民航总医院药剂科2012年2月至2013年1月门诊药房非惩罚性用药错误报告系统的报告,筛选出调剂差错,按照差错发生率、差错分级、差错内容、引发差错原因、差错发生时间、差错药品分类及引发和发现差错人员进行分析. 结果 共纳入130例调剂差错报告.2012年2月、7月和8月差错报告较多,差错发生率分别为0.037％、0.022％及0.034％,全年调剂差错发生率0.009％.130例报告中,A、B及C级差错分别为4例(3.1％)、120例(92.3％)及6例(4.6％).126例B及C级差错报告的引发人员依次为初级药师(108例)、实习人员(13例)和中级药师(5例),发现人员依次为中级药师(95例)、初级药师(30例)、护士(2例)、患者(2例)和高级药师(1例);差错内容以药物品种差错最为多见,占73.8％.130例报告中,以药名相似为错误原因者最多,占34.6％.差错发生时间主要集中在8∶00至10∶59及13∶00至14∶59.126例B级及C级报告中,西药、中成药、高危药品和麻醉药品差错报告占比分别为57.9％(73例,涉及129种药品)、38.1％(48例,涉及74种药品)、3.2％(4例,涉及3种药品)和0.8％(1例,涉及2种药品). 结论 可通过更新设施、规范药品摆放、优化工作规范和流程、加强教育培训、建设非惩罚性安全用药文化等措施防范调剂差错.
目的 分析門診藥房藥品調劑差錯髮生情況及改進方嚮. 方法 收集民航總醫院藥劑科2012年2月至2013年1月門診藥房非懲罰性用藥錯誤報告繫統的報告,篩選齣調劑差錯,按照差錯髮生率、差錯分級、差錯內容、引髮差錯原因、差錯髮生時間、差錯藥品分類及引髮和髮現差錯人員進行分析. 結果 共納入130例調劑差錯報告.2012年2月、7月和8月差錯報告較多,差錯髮生率分彆為0.037％、0.022％及0.034％,全年調劑差錯髮生率0.009％.130例報告中,A、B及C級差錯分彆為4例(3.1％)、120例(92.3％)及6例(4.6％).126例B及C級差錯報告的引髮人員依次為初級藥師(108例)、實習人員(13例)和中級藥師(5例),髮現人員依次為中級藥師(95例)、初級藥師(30例)、護士(2例)、患者(2例)和高級藥師(1例);差錯內容以藥物品種差錯最為多見,佔73.8％.130例報告中,以藥名相似為錯誤原因者最多,佔34.6％.差錯髮生時間主要集中在8∶00至10∶59及13∶00至14∶59.126例B級及C級報告中,西藥、中成藥、高危藥品和痳醉藥品差錯報告佔比分彆為57.9％(73例,涉及129種藥品)、38.1％(48例,涉及74種藥品)、3.2％(4例,涉及3種藥品)和0.8％(1例,涉及2種藥品). 結論 可通過更新設施、規範藥品襬放、優化工作規範和流程、加彊教育培訓、建設非懲罰性安全用藥文化等措施防範調劑差錯.
목적 분석문진약방약품조제차착발생정황급개진방향. 방법 수집민항총의원약제과2012년2월지2013년1월문진약방비징벌성용약착오보고계통적보고,사선출조제차착,안조차착발생솔、차착분급、차착내용、인발차착원인、차착발생시간、차착약품분류급인발화발현차착인원진행분석. 결과 공납입130례조제차착보고.2012년2월、7월화8월차착보고교다,차착발생솔분별위0.037％、0.022％급0.034％,전년조제차착발생솔0.009％.130례보고중,A、B급C급차착분별위4례(3.1％)、120례(92.3％)급6례(4.6％).126례B급C급차착보고적인발인원의차위초급약사(108례)、실습인원(13례)화중급약사(5례),발현인원의차위중급약사(95례)、초급약사(30례)、호사(2례)、환자(2례)화고급약사(1례);차착내용이약물품충차착최위다견,점73.8％.130례보고중,이약명상사위착오원인자최다,점34.6％.차착발생시간주요집중재8∶00지10∶59급13∶00지14∶59.126례B급급C급보고중,서약、중성약、고위약품화마취약품차착보고점비분별위57.9％(73례,섭급129충약품)、38.1％(48례,섭급74충약품)、3.2％(4례,섭급3충약품)화0.8％(1례,섭급2충약품). 결론 가통과경신설시、규범약품파방、우화공작규범화류정、가강교육배훈、건설비징벌성안전용약문화등조시방범조제차착.
Objective To analyze occurrence situation and improvement direction of drug dispensing errors at outpatient pharmacy.Methods Reports in non-punitive medication error reporting system at outpatient pharmacy of Civil Aviation General Hospital from February 2012 to January 2013 were collected.Cases of drug dispensing errors were selected and analyzed according to incidence,category,content,triggering cause,occurrence time,and drug classification of errors and persons who triggered or detected errors.Results One hundred and thirty cases of drug dispensing errors were included.Error cases occurred mainly in February,July,and August and the incidences were 0.037％,0.022％,and 0.034％,respectively.The incidence of drug dispensing errors in the whole year was 0.009％.Of the 130 cases,errors of category A,B,and C were respectively 4 cases (3.1％),120 cases (92.3％),and 6 cases (4.6％).The persons who triggered errors of 126 cases of category B and C were respectively elementary pharmacists (108 cases),interns (13 cases),and intermediate pharmacists (5 cases).The persons who detected errors of 126 cases of category B and C were respectively intermediate pharmacists (95 cases),primary pharmacists (30 cases),nurses (2 cases),patients (2 cases),and senior pharmacist (1 case).The most common errors content was errors of drug varieties which accounted for 73.8％.Of the 130 cases,sound-alike drugs caused the most errors which accounted for 34.6％.The errors occurred mainly from 8∶00 to 10∶59 and from 13∶00 to 14∶59.Of 126 cases of category B and C,proportions of western medicine,Chinese patent medicine,high-risk drug,and narcotic drug were respectively 57.9％ (73cases,involving 129 kinds of drugs),38.1％ (48 cases,involving 74 kinds of drugs),3.2％ (4 cases,involving 3 kinds of drugs),and 0.8％ (1 case,involving 2 kinds of drugs).Conclusion Drug dispensing errors could be prevented by renewing facility,managing drug location,optimizing work norm and procedure,strengthening education and training,and constructing culture of non-punitive drug safety.
