CAJ | 학술논문

目的了解北京地区用药错误(ME)报告的现状,进一步完善ME监测报告系统.方法收集2012年北京22家医院药学部门报告的ME案例进行分析,项目包括ME分级、分类、引发因素和引发及发现ME的人数及构成比.A级ME为差错隐患,B、C、D级为未对患者造成伤害的轻型ME,E、F、G、H、I级为对患者造成伤害甚至导致死亡的严重型ME. 结果 2012年北京22家医院共报告ME 1165例.A、B、C、D、E、F级ME分别占5.9％(69例)、71.9％(837例)、19.3％(225例)、2.2％(26例)、0.5％(6例)、0.2％(2例),G、H、I级未有报告.1165例ME报告中共记录1220例次分类错误,其中药物品种错误比例最高,达27.2％(332例次),给药途径、剂量、时间错误分别占12.0％(147例次)、14.3％(175例次)、7.1％(86例次).药物品种和给药途径、时间等错误中包括不合理用药内容.1165例ME报告共记录有1183例次ME引发因素,排在前3位的因素为药品名称相似、处方错误和外观相似,分别占19.1％(226例次)、14.0％(166例次)和8.3％(98例次).引发人员中,医师、药师、护士、患者或家属占比分别为66.0％、30.6％、1.1％、2.3％；发现ME人员中,医师、药师、护士、患者或家属占比分别为1.4％、88.8％、4.6％、5.2％. 结论北京ME报告系统已趋于成熟,其运作模式可供创建国家级ME监测报告体系借鉴.
목적 료해북경지구용약착오(ME)보고적현상,진일보완선ME감측보고계통.방법 수집2012년북경22가의원약학부문보고적ME안례진행분석,항목포괄ME분급、분류、인발인소화인발급발현ME적인수급구성비.A급ME위차착은환,B、C、D급위미대환자조성상해적경형ME,E、F、G、H、I급위대환자조성상해심지도치사망적엄중형ME. 결과 2012년북경22가의원공보고ME 1165례.A、B、C、D、E、F급ME분별점5.9％(69례)、71.9％(837례)、19.3％(225례)、2.2％(26례)、0.5％(6례)、0.2％(2례),G、H、I급미유보고.1165례ME보고중공기록1220례차분류착오,기중약물품충착오비례최고,체27.2％(332례차),급약도경、제량、시간착오분별점12.0％(147례차)、14.3％(175례차)、7.1％(86례차).약물품충화급약도경、시간등착오중포괄불합리용약내용.1165례ME보고공기록유1183례차ME인발인소,배재전3위적인소위약품명칭상사、처방착오화외관상사,분별점19.1％(226례차)、14.0％(166례차)화8.3％(98례차).인발인원중,의사、약사、호사、환자혹가속점비분별위66.0％、30.6％、1.1％、2.3％；발현ME인원중,의사、약사、호사、환자혹가속점비분별위1.4％、88.8％、4.6％、5.2％. 결론 북경ME보고계통이추우성숙,기운작모식가공창건국가급ME감측보고체계차감.
Objective To understand the current status of medication errors (ME) report in Beijing area and improve the ME monitor and report system.Methods ME cases which were reported by pharmacy departments of 22 hospitals in Beijing in 2012 were collected and analyzed.Analysis projects included category,classification,and triggering factor of ME and the number and proportion of persons who triggered or detected ME.Category A is potential error.Category B,C,and D are mild ME which did not harm patients.Category E,F,G,H,and I are severe ME which cause harm to patients even death.Results One thousand one hundred and sixty-five cases of ME were totally reported by 22 hospitals in Beijing.Proportion of ME of category A,B,C,D,E,and F were respectively 5.9％ (69 cases),71.9％ (837 cases),19.3％ (225 cases),2.2％ (26 cases),0.5％ (6 cases),and 0.2％ (2 cases).ME of category G,H,and I have not been reported.In 1165 reports of ME,1220 errors of classification were noted.Therein,the error of kinds of medications was the highest proportion which reached 27.2％ (332 errors).The errors of administration route,dosage,and time respectively accounted for 12.0％ (147 errors),14.3％ (175 errors),and 7.1％ (86 errors).The content of unreasonable drug use was contained in the errors of kinds of medications,administration route and time.In 1165 reports of ME,1183 triggering factors were noted.The top three factors were sound alike,prescribing errors,and look alike,whose proportions were 19.1％ (226 errors),14.0％ (166 errors),and 8.3％ (98 errors),respectively.In terms of the persons that triggered ME,the proportions of doctors,pharmacists,nurses,and patients or families were respectively 66.0％,30.6％,1.1％,and 2.3％.In terms of the persons who detected ME,doctors,pharmacists,nurses,and patients or family members respectively accounted for 1.4％,88.8％,4.6％,and 5.2％.Concluions The report system of ME in Beijing had tended to be mature gradually.The operation model could be used for reference for national systems of ME monitor and report.