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

doi:10.19803/j.1672-8629.2022.09.23

中国药物警戒 ›› 2022, Vol. 19 ›› Issue (9): 1040-1044.
DOI: 10.19803/j.1672-8629.2022.09.23

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

张青霞¹, 江永贤^2,Δ, 李根², 闫素英¹, 王育琴^1,*

¹首都医科大学宣武医院药学部,北京 100053;
²电子科技大学医学院附属妇女儿童医院,成都市妇女儿童中心医院药学部,四川成都 611731

收稿日期:2020-11-16 出版日期:2022-09-15 发布日期:2022-09-16
通讯作者: ^*王育琴,女,教授,主任药师,药事管理。E-mail:18601061925@163.com
作者简介:张青霞,女,硕士,副主任药师,用药安全管理及心血管慢病合理用药。^△为共同第一作者
基金资助:
国家重点研发计划（2020YFC2008305）; 北京市科学技术委员会“北京老年人健康评估及维护关键技术研究”项目（D181100000218002）

Analysis and prevention of medication errors related to stored pharmaceuticals in National Monitoring Network for Clinical Safety Medication

ZHANG Qingxia¹, JIANG Yongxian^2,Δ, LI Gen², YAN Suying¹, WANG Yuqin^1,*

¹Department of Pharmacy, Xuanwu Hospital, Capital Medical University, Beijing 100053, China;
²Department of Pharmacy, Chengdu Women’s and Children’s Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu Sichuan 611731, China

Received:2020-11-16 Online:2022-09-15 Published:2022-09-16

摘要/Abstract

摘要： 目的分析药品贮藏安全性的现状并识别药品贮藏环节中的风险点,为医疗机构制定针对性的防范措施提供依据。方法收集全国临床安全用药监测网2012年9月22日至2020年9月30日来自全国的所有药品贮藏相关用药错误（ME）报告,对错误报告涉及药品、错误分级、错误内容、错误环节及错误引发人员、错误因素等内容进行回顾性统计分析。结果临床安全用药监测网收到来自全国15个省市33家医院上报贮藏相关的ME报告67例,上报例数前3名省市分别为北京（24例,35.82%）、安徽（17例,25.37%）和新疆（5例,7.46%）,涉及药品种类15种44个药品,排名前3的药品种类为激素及调节内分泌功能用药（17例,25.37%,例如胰岛素类药品）、影响血液及造血系统药物（12例,11.94%,例如维生素K₁、蔗糖铁注射液）和消化系统用药（7例,10.45%,例如注射用奥美拉唑钠、酪酸梭菌二联活菌胶囊）;错误类型主要为温度相关的贮藏错误37例（55.22%）,与光线相关的错误19例（28.36%）,未远离儿童贮藏相关的错误6例（8.96%）、配置后放置时间过久3例（4.48%）、与湿度相关的错误2例（2.99%）;错误分级：B级错误最多,有43例（64.18%）,C级9例（13.43%）,D级6例（8.96%）,E级5例（7.46%）和F级4例（5.97%）;涉及的错误人员：药师16例（23.88%）,护士24例（35.86%）,患者及家属21例（31.34%）,医生4例（5.97%）和设备相关2例（2.99%）。67例ME案例中共有92个诱发因素,单因素诱发者46例,双因素诱发者17例,三因素诱发者4例;其中最常见的是知识欠缺、培训不足和个人疏忽。结论药品贮藏ME具有普遍性,涉及医、药、护、患、设备多个环节,涉及最多的药品是胰岛素类和喹诺酮类药物,错误内容以贮藏温度不当最多,伤害程度最多的是药品未远离儿童贮藏。医院相关部门应从药品流通的各个环节重视药品贮藏问题,从而保障临床用药安全有效及避免患者伤害。

关键词: 用药错误, 贮藏管理, 风险防范, 患者安全

Abstract: Objective To analyze the current drug storage safety and identify the risks in the storage process of drugs so as to provide data for targeted precautions. Methods Reports about drug storage-related medication error (ME) were collected from the National Monitoring Network for Clinical Safety Medication between September 22, 2012 and September 30, 2020. The types of drugs involved, severity of errors, types of errors, where errors were made, the personnel who made these errors, and causes of errors were retrospectively analyzed statistically. Results The National Monitoring Network for Clinical Safety Medication received 67 storage-related ME reports from 33 hospitals in 15 provinces and cities across the country. The top three provinces and cities in terms of the number of reported cases were Beijing (24 cases, 35.82%), Anhui (17 cases, 25.37%) and Xinjiang (5 cases, 7.46%), involving 15 types of drugs. The top three types of drugs were hormones and endocrine-regulating drugs (17 cases, 25.37%), drugs for hematopoiesis (12 cases, 11.94%) and drugs for digestive diseases (7 cases,10.45%,). As for types of errors, there were 37 cases of temperature-related storage errors (55.22%), 19 cases (28.36%) of light-related errors, 6 cases (8.96%) of errors resulting from storage too close to children, and 3 cases (4.48%) of errors arising from too long storage after preparation, and 2 cases of humidity-related errors (2.99%). When it came to severity of errors, errors of class B were dominating (43 cases, 64.18%), followed by those of class C (9 cases, 13.43%), class D (6 cases, 8.96%), and class E (5 cases, 7.46%) and class F (4 cases, 5.97%). These errors involved 16 pharmacists (23.88%), 24 nurses (35.86%), 21 patients and family members (31.34%), 4 doctors (5.97 %) and equipment (2 cases, 2.99%). The most common causes of errors were lack of knowledge, insufficient training and personal negligence. Conclusion MEs relating to drug storage are not uncommon and have a wide range of causes. Related departments of hospitals should pay more attention to drug storage in the whole process of drug circulation so as to ensure the safety and effectiveness of clinical medications.

Key words: medication errors, storage management, risk prevention, patient safety

中图分类号:

R969.3

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.

ZHANG Qingxia, JIANG Yongxian, LI Gen, YAN Suying, WANG Yuqin. Analysis and prevention of medication errors related to stored pharmaceuticals in National Monitoring Network for Clinical Safety Medication[J]. Chinese Journal of Pharmacovigilance, 2022, 19(9): 1040-1044.

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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

Analysis and prevention of medication errors related to stored pharmaceuticals in National Monitoring Network for Clinical Safety Medication

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