某中医院500例用药错误隐患的发现与分析
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摘要
目的研究某中医医院用药错误(ME)发生的原因并分析其对策。方法采用根本原因分析法(RCA)回顾性分析2016年1-6月500例ME,分析其发生的原因。结果 ME主要发生在诊室和药房,分别占72.00%和27.40%。中成药ME共105例,化药ME共395例,两者错误分级及错误构成相似。药品品种错误比例最高占25.00%,其次为药品数量错误为19.60%,药品用量错误第三,占13.20%。疲劳为引发ME最主要原因,占32.20%,其次为知识欠缺和技术不熟练。医师占ME引发人员63.40%,药师占35.60%。发现ME的人员药师占81.20%,护士占16.80%。结论应加强医院信息系统权限设置及维护,增加ME相关培训,制定管理制度激励医务人员上报ME,加强医务人员相关药学知识培训等措施来减少ME的发生。
Objective To determine the reasons for medication errors(ME) in a traditional Chinese hospital. Methods Totally 500 cases of ME from January 2016 to June 2016 were retrospectively analyzed by root cause analysis(RCA). Results ME mainly occurred in the cousultation rooms and pharmacy, accounting for 72.00% and 27.40% respectively. Chinese medicine ME reached 105 cases, and the other 395 MEs were chemical drugs, with similar error classification and error constitute. The highest proportion of drug variety accounted for 25.00%, followed by wrong number of drugs(19.60%), and drug dosage(13.20%). Fatigue was the main cause of MEs(32.20%), followed by the lack of knowledge and unskillful technology. Physicians were responsible for 63.40% of the ME, while pharmacists for 35.60%. Those who detected ME included pharmacists(81.20%), and nurses(16.80%). Conclusion It is necessary to strengthen the establishment and maintenance of hospital information system authority, increase ME related training, formulate management system to encourage medical personnels to report ME, and increase pharmaceutical knowledge training to reduce MEs.
Objective To determine the reasons for medication errors(ME) in a traditional Chinese hospital. Methods Totally 500 cases of ME from January 2016 to June 2016 were retrospectively analyzed by root cause analysis(RCA). Results ME mainly occurred in the cousultation rooms and pharmacy, accounting for 72.00% and 27.40% respectively. Chinese medicine ME reached 105 cases, and the other 395 MEs were chemical drugs, with similar error classification and error constitute. The highest proportion of drug variety accounted for 25.00%, followed by wrong number of drugs(19.60%), and drug dosage(13.20%). Fatigue was the main cause of MEs(32.20%), followed by the lack of knowledge and unskillful technology. Physicians were responsible for 63.40% of the ME, while pharmacists for 35.60%. Those who detected ME included pharmacists(81.20%), and nurses(16.80%). Conclusion It is necessary to strengthen the establishment and maintenance of hospital information system authority, increase ME related training, formulate management system to encourage medical personnels to report ME, and increase pharmaceutical knowledge training to reduce MEs.
引文
[1]中华人民共和国国家卫生和计划生育委员会.卫生部国家中医药管理局总后勤部卫生部关于印发《医疗机构药事管理规定》的通知[EB/OL].http://www.nhfpc.gov.cn/mohyzs/s3585/201103/51113.shtml,2011-01-30/2017-08-06.
[2]Wittich CM,Burkle CM,Lanier WL.Medication errors:an overview for clinicians[J].Mayo Clin Proc,2014,89(8):1116-1125.
[3]Ohashi K,Dalleur O,Dykes PC,et al.Benefits and risks of using smart pumps to reduce medication error rates:a systematic review[J].Drug Saf,2014,37(12):1011-1020.
[4]盛文佳,金可可,曹艳佩,等.根本原因分析法实践研究[J].中国卫生质量管理,2011,18(1):20-22.
[5]Latino RJ.How is the effectiveness of root cause analysis measured in healthcare?[J].J Healthc Risk Manag,2015,35(2):21-30.
[6]Shaqdan K,Aran S,Abujudeh H,et al.Root-cause analysis and health failure mode and effect analysis:two leading techniques in health care quality assessment[J].J Am Coll Radiol,2014,11(6):572-579.
[7]Venier AG.Root cause analysis to support infection control in healthcare premises[J].J Hosp Infect,2015,89(4):331-334.
[8]贾艾莎,李晓玲.合理用药国际网络中国中心组临床安全用药组成立大会暨第一次工作会议纪要[J].药物不良反应杂志,2012,14(5):335-337.
[9]朱忱,崔璨,李晓玲,等.281例抗肿瘤药物用药错误分析[J].中国药物警戒,2017,14(1):40-44.
[10]马丽萍,吝战权,沈司京.我院门诊处方中26例高危药品用药错误的原因分析及防范措施[J].中国药房,2015,26(35):4925-4928.
[11]韩晓娟,丁选胜,王俐,等.妇科内分泌症患者性激素类药物用药错误分析[J].中国医院药学杂志,2012,32(13):1068-1070.
[12]董迪,宋菲,陈宁,等.242例老年患者用药错误回顾性分析[J].临床药物治疗杂志,2017,15(5):52-55.
[13]合理用药国际网络中国中心组临床安全用药组,中国药理学会药源性疾病学专业委员会,中国药学会医院药学专业委员会,等.中国用药错误管理专家共识[J].药物不良反应杂志,2014,16(6):321-326.
[14]Croteau RJ.Identifying and addressing sentinel events:an interview with Richard Croteau.Interview by Steven Berman[J].Jt Comm J Qual Improv,1998,24(8):426-434.
[15]National coordinating council for medication error reporting and prevention.Types of medication errors[EB/OL].http://www.nccmerp.org/types-medication-errors,2001-02-20/2017-08-04.
[16]陈宁,王婷,马莉.345例用药错误原因分析及对策[J].中国药物警戒,2015,12(2):106-109.
[17]中华人民共和国国家卫生和计划生育委员会.卫生部办公厅关于印发《三级综合医院评审标准实施细则(2011年版)的通知》[EB/OL].http://www.nhfpc.gov.cn/zwgk/wtwj/201304/0404f9cd71764ab29b2365e069cfbf2d.shtml,2011-11-25/2017-08-06.
[18]陶婧婧,高星,袁素维,等.北京市改革试点公立医院医务人员工作状况研究[J].上海交通大学学报:医学版,2013,33(6):717-723.
[19]朱春梅,吴民,赵江琳.7种中药注射液在生理盐水中的稳定性考察[J].西北药学杂志,2009,24(5):389-390.
[20]朱建成,肖淼生,宋登鹏,等.参麦注射液与5种输液配伍稳定性考察[J].医药导报,2009,28(2):259-260.
[21]杜燕京,王淑玲,封宇飞,等.医院用药错误的成因及防范策略分析[J].中国药业,2015,24(7):64-66.
[22]黄如敏.重庆市某医院药剂用药错误原因分析[J].中国卫生产业,2016,13(35):163-165.
[2]Wittich CM,Burkle CM,Lanier WL.Medication errors:an overview for clinicians[J].Mayo Clin Proc,2014,89(8):1116-1125.
[3]Ohashi K,Dalleur O,Dykes PC,et al.Benefits and risks of using smart pumps to reduce medication error rates:a systematic review[J].Drug Saf,2014,37(12):1011-1020.
[4]盛文佳,金可可,曹艳佩,等.根本原因分析法实践研究[J].中国卫生质量管理,2011,18(1):20-22.
[5]Latino RJ.How is the effectiveness of root cause analysis measured in healthcare?[J].J Healthc Risk Manag,2015,35(2):21-30.
[6]Shaqdan K,Aran S,Abujudeh H,et al.Root-cause analysis and health failure mode and effect analysis:two leading techniques in health care quality assessment[J].J Am Coll Radiol,2014,11(6):572-579.
[7]Venier AG.Root cause analysis to support infection control in healthcare premises[J].J Hosp Infect,2015,89(4):331-334.
[8]贾艾莎,李晓玲.合理用药国际网络中国中心组临床安全用药组成立大会暨第一次工作会议纪要[J].药物不良反应杂志,2012,14(5):335-337.
[9]朱忱,崔璨,李晓玲,等.281例抗肿瘤药物用药错误分析[J].中国药物警戒,2017,14(1):40-44.
[10]马丽萍,吝战权,沈司京.我院门诊处方中26例高危药品用药错误的原因分析及防范措施[J].中国药房,2015,26(35):4925-4928.
[11]韩晓娟,丁选胜,王俐,等.妇科内分泌症患者性激素类药物用药错误分析[J].中国医院药学杂志,2012,32(13):1068-1070.
[12]董迪,宋菲,陈宁,等.242例老年患者用药错误回顾性分析[J].临床药物治疗杂志,2017,15(5):52-55.
[13]合理用药国际网络中国中心组临床安全用药组,中国药理学会药源性疾病学专业委员会,中国药学会医院药学专业委员会,等.中国用药错误管理专家共识[J].药物不良反应杂志,2014,16(6):321-326.
[14]Croteau RJ.Identifying and addressing sentinel events:an interview with Richard Croteau.Interview by Steven Berman[J].Jt Comm J Qual Improv,1998,24(8):426-434.
[15]National coordinating council for medication error reporting and prevention.Types of medication errors[EB/OL].http://www.nccmerp.org/types-medication-errors,2001-02-20/2017-08-04.
[16]陈宁,王婷,马莉.345例用药错误原因分析及对策[J].中国药物警戒,2015,12(2):106-109.
[17]中华人民共和国国家卫生和计划生育委员会.卫生部办公厅关于印发《三级综合医院评审标准实施细则(2011年版)的通知》[EB/OL].http://www.nhfpc.gov.cn/zwgk/wtwj/201304/0404f9cd71764ab29b2365e069cfbf2d.shtml,2011-11-25/2017-08-06.
[18]陶婧婧,高星,袁素维,等.北京市改革试点公立医院医务人员工作状况研究[J].上海交通大学学报:医学版,2013,33(6):717-723.
[19]朱春梅,吴民,赵江琳.7种中药注射液在生理盐水中的稳定性考察[J].西北药学杂志,2009,24(5):389-390.
[20]朱建成,肖淼生,宋登鹏,等.参麦注射液与5种输液配伍稳定性考察[J].医药导报,2009,28(2):259-260.
[21]杜燕京,王淑玲,封宇飞,等.医院用药错误的成因及防范策略分析[J].中国药业,2015,24(7):64-66.
[22]黄如敏.重庆市某医院药剂用药错误原因分析[J].中国卫生产业,2016,13(35):163-165.