他汀类药物1028例用药错误报告分析及防范策略

doi:10.19803/j.1672-8629.2022.06.13

中国药物警戒 ›› 2022, Vol. 19 ›› Issue (6): 645-648.
DOI: 10.19803/j.1672-8629.2022.06.13

他汀类药物1028例用药错误报告分析及防范策略

邵晨, 张青霞^Δ*, 闫素英, 王育琴

首都医科大学宣武医院药学部,国家老年疾病临床医学研究中心,北京 100053

收稿日期:2021-10-17 出版日期:2022-06-15 发布日期:2022-06-13
通讯作者: ^* 张青霞,女,硕士,副主任药师,用药安全和心血管药物治疗管理。E-mail：Wl7322681@sina.com
作者简介:邵晨,女,硕士,药师,医院药学和临床药学。^Δ为并列第一作者。
基金资助:
国家重点研发计划（2020YFC2008305）; 北京市科学技术委员会“老年人多重用药管理模式的建立与临床应用研究”专项资助课题（D181100000218002）

Analysis of 1028 statins-related medication errors and prevention strategies

SHAO Chen, ZHANG Qingxia^Δ*, YAN Suying, WANG Yuqin

Department of Pharmacy, Xuanwu Hospital Capital Medical University, National Clinical Research Center for Geriatric Disorders, Beijing 100053, China

Received:2021-10-17 Online:2022-06-15 Published:2022-06-13

摘要/Abstract

摘要： 目的了解我国他汀类药物用药错误（ME）发生情况及影响因素,为制定针对性防范措施提供依据,保障患者用药安全。方法收集全国临床安全用药监测网2016年1月1日至2020年12月31日他汀类药物ME报告,对ME的分级、错误内容、引发人员、发现人员和引发因素进行分析。结果 1 028例ME报告来自23个省市132家医院,B级最多（848例,82.49%）,严重ME 5例（0.49%）。错误内容主要是品种错误,300例次（29.10%,主要因素是药品看似听似）。5例严重ME的错误内容是：相互作用2例、禁忌证1例、用量1例、重复给药1例。医生是引发ME的主要人员,515例（50.10%,主要错误是重复给药）。发现ME人员主要是药师,849例次（79.72%）。引发ME的主要错误因素是人员因素,590例次（52.73%,主要是疲劳和知识欠缺）。结论他汀类药物ME以B级为主,多由看似听似药品引起。严重ME需要关注药物相互作用。ME主要由医生引发,错误因素主要是疲劳和知识欠缺等。建议加强人员合理用药培训,减少医务人员工作压力,强化信息化建设和药品遴选,以减少看似听似错误风险,保障患者用药安全和医务人员执业安全。

关键词: 他汀类药物, 用药错误, 用药安全, 风险防范

Abstract: Objective To investigate the incidence and causes of medication errors (ME) related to statins in China in order to formulate targeted preventive measures and ensure the safety of drug use in patients. Methods ME reports were collected from the National Monitoring Network for Clinical Safe Drug Use from January 1, 2016 to December 31, 2020, and analyzed in terms of the origin, classification, drugs involved, types of errors, personnel responsible, discovers of errors and causes of errors. Results A total of 1 028 ME reports were collected from 132 hospitals in 23 provinces and cities. Most of these reports involved grade B errors (848 cases, 82.49%), and there were 5 cases of severe ME (0.49%). Many of these errors were related to the variety, involving 300 cases (29.10%, LASA drugs). The five serious ME errors involved drugs interactions (2 cases), contraindications (1 case), dosage (1 case), and repeated administration (1 case). Those most responsible for ME were doctors, involving 515 cases (50.10%, and the main cause of errors was repeated administration). 849 cases of errors (79.72%) were found by pharmacists. Most of these ME were due to human factors, involving 590 cases (52.73%, mainly because of fatigue and lack of knowledge). Conclusion Statins-related ME are mostly of grade B and caused by LASA. It is recommended that clinicians be better informed of rational drug use, and that the stress of health care providers be reduced so as to lower the risk of LASA errors and ensure the drug safety of patients.

Key words: statins, medication errors, medication safety, risk prevention

中图分类号:

R994.1

邵晨, 张青霞, 闫素英, 王育琴. 他汀类药物1028例用药错误报告分析及防范策略[J]. 中国药物警戒, 2022, 19(6): 645-648.

SHAO Chen, ZHANG Qingxia, YAN Suying, WANG Yuqin. Analysis of 1028 statins-related medication errors and prevention strategies[J]. Chinese Journal of Pharmacovigilance, 2022, 19(6): 645-648.

参考文献

[1] Joint Committee on the revision of guidelines for the prevention and treatment of dyslipidemia in adults in China. Guidelines for the prevention and treatment of dyslipidemia in adults in China (2016 Revised Edition)[J]. Chinese Circulation Journal(中国循环杂志),2016, 31(10): 937-950.
[2] ZHANG QX, ZHANG YZ, ZENG Y, et al.Analysis of medication errors in patients with hyperuricemia/gout based on national monitoring network for clinical safe drug use[J]. China Pharmacy(中国药房), 2021, 32(15): 1894-1898.
[3] ZHANG QX, WANG YW, LI XL, et al.Annual report of national monitoring network for clinical safe medication(2020)[J]. Adverse Drug Reactions Journal(药物不良反应杂志),2021, 23(5): 228-234.
[4] JIA AS, LI XL.Summary of the conference on the establishment and the First Working Meeting of the Medication Safety Panel in China Core Group of International Network for the Rational Use of Drugs[J]. Adverse Drug Reactions Journal(药物不良反应杂志),2012, 14(5): 335-337.
[5] ZHANG QX, WANG YW, LI XL, et al.Annual report on clinical medication safety of National Monitoring Network for Clinical Safe Medication(2018)[J]. Adverse Drug Reactions Journal(药物不良反应杂志), 2019, 21(1): 2-8.
[6] ZHANG QX, WANG YW, LI XL, et al.Annual report on clinical medication safety of National Monitoring Network for Clinical Safe Medication(2019)[J]. Adverse Drug Reactions Journal(药物不良反应杂志), 2020, 22(9): 499-504.
[7] Medication Safety Panel in China Core Group of International Network for the Rational Use of Drug(INRUD), Chinese Pharmacological Society Professional Committee of Drug-induced Diseases, Chinese Pharmaceutical Association Professional Committee of Hospital Pharmacy, et al. Expert consensus on medication error management in China[J]. Journal of Adverse Drug Reactions(药物不良反应杂志), 2014, 16(6): 321-326.
[8] ZHANG QX, YAN SY, LI XL, et al.Analysis on reports of medication errors with methotrexate tablets in National Monitoring Network for Clinical safe Medication from 2012 to 2017[J]. Adverse Drug Reactions Journal(药物不良反应杂志), 2018, 20(3): 187-192.
[9] WANG ZM, ZHANG QX, YAN SY, et al.Analysis of reports on medication error in our hospital from 2016 to 2017[J]. Practical Pharmacy And Clinical Remedies(实用药物与临床),2019, 22(12): 1324-1327.
[10] BATES DW, CULLEN DJ, LAIRD N, et al.Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group[J]. JAMA, 1995, 274(1): 29-34.
[11] WANG J, CUI XH, JIANG DC, et al.The establishment of prescription pre-examination system and its effect on the quality of the prescription in the outpatients and emergency patients[J]. Clinical Medication Journal(临床药物治疗杂志), 2018, 16(9):68-71.
[12] CUI XH, YAN SY, JIANG DC, et al.Design and preliminary application of pre-audit system for medical orders in hospitalized patients[J]. Adverse Drug Reactions Journal(药物不良反应杂志),2018, 20(2): 122-127.
[13] SHAO C, CHU YQ, CUI XH, et al.The effect of prescription pre-checking system in inpatient medication safety[J]. Clinical Medication Journal(临床药物治疗杂志), 2020, 18(1): 51-54.
[14] ZHANG H, JIA N, ZHANG YT, et al.Analysis of Effects of Drug-drug Interactions on Safety and Efficacy of Atorvastatin[J]. Chinese Journal of Pharmacovigilance(中国药物警戒), 2019, 16(1): 43-46.
[15] ZHANG X, GU YX.Literature review of 141 cases of adverse drug reactions induced by simvastatin[J]. Chinese Journal of Pharmacovigilance(中国药物警戒), 2019, 16(8): 487-491.

他汀类药物1028例用药错误报告分析及防范策略

Analysis of 1028 statins-related medication errors and prevention strategies

PDF (PC)

可视化

摘要/Abstract

引用本文

使用本文

参考文献

相关文章 15

编辑推荐

Metrics

[1]	袁偲偲, 王广燕, 李轶凡, 李瑞莲, 杜博冉, 冯欣. 基于失效模式与效应分析的麻精药品临床管理安全相关风险因素研究[J]. 中国药物警戒, 2023, 20(9): 1027-1030.
[2]	王然, 冯欣, 杜博冉. 围孕期妊娠用药暴露风险评价与药学实践进展[J]. 中国药物警戒, 2023, 20(7): 836-840.
[3]	张青霞, 周柳君, 李晓玲, 王育琴. 老年人头孢哌酮舒巴坦用药错误报告分析与建议[J]. 中国药物警戒, 2023, 20(5): 574-578.
[4]	丁倩, 李博宇, 张青霞. 硝酸甘油开封后贮藏风险调查与防范[J]. 中国药物警戒, 2023, 20(3): 326-330.
[5]	蒋建东. 我国儿童药品研发与临床用药安全展望[J]. 中国药物警戒, 2023, 20(1): 1-6.
[6]	褚燕琦, 江永贤, 沈江华, 邢晓璇, 张青霞, 闫素英. 老年患者胸腔镜术后镇痛使用风险调查及防范[J]. 中国药物警戒, 2022, 19(9): 1023-1026.
[7]	张青霞, 江永贤, 李根, 闫素英, 王育琴. 全国临床安全用药监测网贮藏用药错误案例分析及风险点防范[J]. 中国药物警戒, 2022, 19(9): 1040-1044.
[8]	张青霞, 江永贤, 董月鑫, 咸颖, 闫素英. 某三甲医院西药药品说明书贮藏条件风险分析及防范建议[J]. 中国药物警戒, 2022, 19(8): 913-918.
[9]	王琚丽, 张晓朦, 张冰, 吕锦涛. 基层医疗机构心血管系统疾病治疗用药的安全性问题分析与警戒思考[J]. 中国药物警戒, 2022, 19(7): 744-748.
[10]	邰新娟, 马洪凤, 李君, 马维兴, 闫亚卫. 400例抗肿瘤药品不良反应报告分析[J]. 中国药物警戒, 2022, 19(5): 541-544.
[11]	王新, 张捷, 张明, 张楠, 艾超. 乙酰半胱氨酸胶囊联合福多司坦片致多形红斑型药疹1例分析[J]. 中国药物警戒, 2022, 19(2): 217-218.
[12]	张青霞, 丁倩, 闫素英, 王育琴. 达比加群酯和利伐沙班用药错误报告分析及防范策略[J]. 中国药物警戒, 2022, 19(12): 1372-1375.
[13]	张青霞, 江永贤, 董月鑫, 咸颖, 王育琴, 闫素英. 胰岛素贮藏风险调查和典型用药错误案例分析与防范[J]. 中国药物警戒, 2022, 19(11): 1242-1245.
[14]	吴颖其, 朱婷, 童彤, 李民, 沈爱宗. 白蛋白结合型紫杉醇不良反应/事件相关因素分析[J]. 中国药物警戒, 2022, 19(10): 1123-1127.
[15]	白荷荷, 聂晓静, 夏丽, 马莉, 王金萍, 彭莉蓉. 基于中国医院药物警戒系统开展药品不良反应监测的效果评价[J]. 中国药物警戒, 2022, 19(10): 1136-1139.