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1、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
2、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
3、低用药风险非常必要。［关键词］用药错误；成因；防范对策Analysison62casesofmedicationerrorsreportingCHENGWen-na，HANYe-kun，DINGZhao-xing，DINGChang-ling，LIUYi-sheng(AffiliatedHospitalOfBinzhouMedicalCollege,ShandongBinzhou256603)[Abstract]ObjectiveToanalyzethecausesofmedicationerrorsandseekcounterme
4、asurestoreduceerrors.MethodsRegistrationofthemedicationerrorsinDepartmentofPharmacyandqaulityofcareinspectionrecordsinaccordancewiththeerrorcontents,causingerrors,initiationandfounderror,errorconsequencesofclassificationforstatisticalanalysis.ResultsHighestnumberofcase
5、sresulterrorsprojectsfordrugvarietieserrorof13cases,accountingfor21.0%.Doseerrorsin12cases,accountingfor19.4%.Dosageerrorsandsimilarerrorsarepackagedin10cases,accountingfor16.1%.52casesinwhichtheerrorscausedbyjuniortitles,accountingfor83.9%;intermediatepharmacistserror
6、causedeightcases,accountingfor12.9%;seniorerroronecase,accountingfor0.02%;errorscausedonecaseofinterns,accountingfor0.02%.Juniortitlesfounderrorsin22cases,35.5%;intermediategradefounderrorsin30cases,48.4%;seniortitlesfounderrorsinninecases,accountingfor14.5%;62casesfro
7、m44casespharmacistmedicationerrors,accountingfor70.97%;nurses17cases,accountingfor27.42%;doctorsonecase,accountingfor0.16%.In62casesofmedicationerrors，therewere44cases(70.97%)frompharmacists，17cases(27.42%)fromphysicians，1cases(0.16%)from.Nurses.Accordingtotheerrorcons
8、equencesorseverityclassification，therewere55cases（88.7%）withnoerror，5cases（0.08%）oferrorswithoutharmand2cases（0.03%）o
