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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