【摘要】：目的:為減少乃至杜絕門診高危藥品的用藥錯誤提供參考。方法:收集2013-2014年我院門診處方點評中發(fā)現(xiàn)的高危藥品用藥錯誤,對用藥錯誤的類型、差錯級別和引發(fā)差錯的因素等進行回顧性分析。結(jié)果:2年共點評處方670 997張,發(fā)現(xiàn)用藥錯誤501例,其中高危藥品的用藥錯誤26例,包括胰島素給藥途徑錯誤7例、口服降糖藥重復用藥和給藥劑量錯誤各1例、阿片類藥品和非甾體抗炎藥重復用藥6例、氨酚待因適應證錯誤2例、葡萄糖注射液規(guī)格錯誤和適應證錯誤各1例、利多卡因給藥途徑錯誤2例、甲氨蝶呤給藥頻率錯誤2例、地高辛給藥劑量錯誤2例、華法林給藥劑量錯誤1例。醫(yī)師處方錯誤,經(jīng)藥師審核發(fā)現(xiàn)錯誤并拒絕調(diào)配的18例,占69.2%;醫(yī)師處方錯誤而藥師未發(fā)現(xiàn)的8例,占30.8%。結(jié)論:門診高危藥品的用藥錯誤主要發(fā)生在醫(yī)師處方環(huán)節(jié),主要原因為電子醫(yī)囑系統(tǒng)沒有實行強制和約束策略。提高門診高危藥品安全用藥水平需要找到差錯環(huán)節(jié)并采取靶向性安全用藥方案。
[Abstract]:Objective: to provide reference for reducing and even eliminating the error of drug use in outpatient high risk drugs. Methods: the errors of high risk drugs found in the evaluation of outpatient prescriptions in our hospital from 2013 to 2014 were collected, and the types of drug errors, the level of errors and the factors causing errors were analyzed retrospectively. the types of drug errors, the levels of errors and the factors causing errors were analyzed retrospectively. Results: a total of 670997 prescriptions were reviewed in 2 years. 501 cases of drug errors were found, including 26 cases of high risk drugs, including 7 cases of insulin administration error, 1 case of oral hypoglycemic drug reuse and 1 case of oral hypoglycemic drug dose error, 6 cases of opioid and non-steroidal anti-inflammatory drugs, 2 cases of aminophenol codeine indication error, 1 case of glucose injection specification error and 1 case of indication error. There were 2 cases of wrong administration route of lidocaine, 2 cases of methotrexate administration frequency error, 2 cases of digoxin administration dose error and 1 case of warfarin administration dose error. 18 cases (69.2%) were found wrong by pharmacists and 8 cases (30.8%) were not found by pharmacists. Conclusion: the drug error of high risk drugs in outpatient department mainly occurs in the link of doctor's prescription, the main reason is that the electronic doctor's order system does not carry out the compulsory and restraint strategy. To improve the level of safe drug use in outpatient department, it is necessary to find the wrong link and adopt the targeted safe drug use scheme.
【作者單位】： 北京大學首鋼醫(yī)院藥劑科;
【分類號】：R969.3

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