我院62例用药错误汇报剖析.doc

62例用药错误报告分析 成文娜，韩叶坤，丁召兴，丁长玲，刘义升 （滨州医学院附属医院） ［摘要］目的 分析用药差错的成因并寻求降低差错的方法和对策。方法 针对药学部用药差错登记、护理部临床护理质量检查登记中的用药差错，按差错内容及引发差错的原因、引发和发现差错的人员、差错后果分类进行分析。结果 出现差错例数最高项目为药物品种差错，共13例，占21.0%。剂量差错12例，占19.4%。剂型差错和包装相似差错均为10例，占16.1%。其中初级职称引发的差错52例，占83.9％；中级药师引发的差错8例，占12.9%；高级职称差错1例，占0.02%；实习生引发的差错1例，占0.02%。初级职称发现差错22例，占35.5%；中级职称发现差错30例，占48.4%；高级职称发现差错9例，占14.5%；62例用药差错来源于药师的44例，占70.97%；护士17例，占27.42%；医师1例，占0.16%。按差错后果或严重程度分类，尚未出现错误55例，占88.7%；出现错误，但未造成伤害5例，占0.08％；出现错误并造成伤害2例，占0.03%；未发生致死性错误。结论 建设非惩罚性安全用药文化，通过更新系统、规范药品摆放、优化工作规范和流程、加强学习、教育培训，及时分析用药差错的根源并采取措施降低用药风险非常必要。 ［关键词］用药错误；成因；防范对策 Analysis on 62 cases of medication errors reporting CHENG Wen-na，HAN Ye-kun，DING Zhao-xing， DING Chang-ling， LIU Yi-sheng (Affiliated Hospital Of Binzhou Medical College, Shandong Binzhou 256603) [Abstract] Objective To analyze the causes of medication errors and seek counter measures to reduce errors.Methods Registration of the medication errors in Department of Pharmacy and qaulity of care inspection records in accordance with the error contents , causing errors , initiation and found error , error consequences of classification for statistical analysis. Results Highest number of cases result errors projects for drug varieties error of 13 cases, accounting for 21.0%.Dose errors in 12 cases, accounting for 19.4%. Dosage errors and similar errors are packaged in 10 cases, accounting for 16.1%. 52 cases in which the errors caused by junior titles , accounting for 83.9% ; intermediate pharmacists error caused eight cases , accounting for 12.9% ; senior error one case , accounting for 0.02% ; errors caused one case of interns , accounting for 0.02%. Junior titles found errors in 22 cases, 35.5% ; intermediate grade found errors in 30 cases, 48.4% ; senior titles found errors in nine cases , accounting for 14.5% ; 62 cases from 44 cases pharmacist medication errors , accounting for 70.97% ; nurses 17 cases, accounting for 27.42% ; doctors one case , accounting for 0.16% . In 62 cases of medication errors，