Analysis of the Cause and Preventive Measures of 26 Cases of Medication Errors of High-alert Drugs in the Outpatient Prescriptions of Our Hospital

目的:为减少乃至杜绝门诊高危药品的用药错误提供参考.方法:收集2013-2014年我院门诊处方点评中发现的高危药品用药错误,对用药错误的类型、差错级别和引发差错的因素等进行回顾性分析.结果:2年共点评处方670 997张,发现用药错误501例,其中高危药品的用药错误26例,包括胰岛素给药途径错误7例、口服降糖药重复用药和给药剂量错误各1例、阿片类药品和非甾体抗炎药重复用药6例、氨酚待因适应证错误2例、葡萄糖注射液规格错误和适应证错误各1例、利多卡因给药途径错误2例、甲氨蝶呤给药频率错误2例、地高辛给药剂量错误2例、华法林给药剂量错误1例.医师处方错误,经药师审核发现错误并拒绝调配的18例,占69.2%;医师处方错误而药师未发现的8例,占30.8%.结论:门诊高危药品的用药错误主要发生在医师处方环节,主要原因为电子医嘱系统没有实行强制和约束策略.提高门诊高危药品安全用药水平需要找到差错环节并采取靶向性安全用药方案.OBJECTIVE:To provide reference for reducing and avoiding medication errors of high-alert drugs in outpatient de-partment. METHODS:The medication errors of high-alert drugs in outpatient prescriptions were collected from our hospital during 2013-2014,and then analyzed retrospectively in terms of the type and degree of medication error,caused factors of medication er-rors,etc. RESULTS:670 997 prescriptions were checked in two years,and 501 medication errors were found,including 26 medi-cation errors of high-alert medication. There were 7 incorrect route of administration of insulin,1 repeated medication and 1 incor-rect dose of oral hypoglycemic agents,6 repeated administration of opioid drugs and non steroidal anti-inflammatory drugs,2 indi-cation error of paracetamol and codeine phosphate,1 specification and 1 indication error of glucose injection,2 route of administra-tion error of lidocaine,2 administration frequency errors of methotrexate,2 dose error of digoxin and 1 dose error of warfarin;18 doctors'prescribing errors were found by pharmacists'prescription audit,accounting for 69.2%;8 doctors'prescribing errors were not found by pharmacists'prescription audit,accounting for 30.8%. CONCLUSIONS:Medication errors of high-alert drugs occur mainly in the prescription segment,and the main reason is that the electronic prescription system lack of compulsory strategy and policy constraints. Improvement of safety administration of high-alert drugs need to find the error link and adopt targeted medi-cation safety practices.中文核心期刊要目总览(PKU)中国科技核心期刊(ISTIC)354925-49282