目的:总结肿瘤专科医院用药错误特点，探讨用药错误(medication error，ME)管理模式。方法:分析北京大学肿瘤医院近10年在合理用药国际网络(International Network for Rational Use of Drug，INRUD)中国中心组临床安全用药监测网站上报告的ME数据，采用回顾性研究和描述性统计方法，分析ME的分级、分类、引发因素、引发人员的例次及其构成比。ME分级参照《中国用药错误管理专家共识》分为4层9级。结果:ME分级中，第2层级中B～C级占比为98。9％，这部分差错未给患者带来伤害。第2层级中D级错误占比为0。94％，这部分错误患者已使用，需要监测错误对患者造成的后果，并根据后果判断是否需要采取措施以减少伤害。第3层级中的E级仅为1例，占比0。16％，这例ME对患者造成暂时性伤害，需要采取处置措施。未收到第4层级报告。药师导致的ME比例最高，其中数量错误例次数所占比例最高(34。48％)，其次为品种错误(31。35％)。ME引发错误因素中，人员因素位列第一，占比59。40％，其中核对环节缺失或无效导致的ME例数最多，共计197例;药品因素位于第二，占比21。63％，其中药名与外观相似药品引起的ME占19。75％。结论:用药错误管理小组的建立对于ME的工作开展非常必要，医院信息化建设促进了 ME的管理，倡导非惩罚差错上报的管理理念尤为重要。合理安排药师工作岗位，可有效规避差错风险。对易混淆药品的细化管理是防范用药错误的必要手段。利用根因分析法等有效的管理工具进一步提升药事管理质量。
Data analysis and management mode of medication error reporting in a cancer special hospital
OBJECTIVE To summarize the characteristics of medication errors(MEs)in cancer hospitals and provide refer-ence for exploring ME management strategies.METHODS The retrospective study analyzed the ME data reported by a cancer hospital on the International Network for Rational Use of Drugs(INRUD)website over the past decade.Adopted descriptive sta-tistical analysis methods were used.ME grading,classifications,triggering factors,number of triggering personnel,and their composition ratios were analyzed.The ME grading was based on the"Expert Consensus on Medication Error Management in China"and divided into four levels and nine sub-levels.RESULTS In the ME classification,level 2 grades B to C accounted for 98.9％,which did not cause harm to the patients.Level 2 grade D errors accounted for 0.94％,which required monitoring for potential harm,and measures were needed to reduce harm based on the consequences.Only one case(0.16％)belonged to level 3 grade E,which caused temporary harm and required intervention.No level 4 ME was reported.Pharmacists caused the highest proportion(34.48％)of ME,followed by variety errors(31.35％).Among the error factors of ME,personnel factors ranked first,accounting for 59.40％,and the largest number of ME cases occurred due to the missing or invalid verification procedures,with 197 cases in total.Drug factors ranked second,accounting for 21.63％,and among them,ME caused by similar name or appearance accounted for 19.75％.CONCLUSION Establishing a medication error management group is necessary.Hospital informatization promotes ME management.A non-punitive approach facilitates error reporting.Reasonably arranging the posi-tions of pharmacists can effectively avoid the risk of errors.Refined management of look-alike/sound-alike drugs helps prevent MEs.Pharmaceutical management quality should be further enhanced by employing effective tools such as root cause analysis.
rational use of drugsmedication errorseasily confused drugpharmacy administrationroot cause analysis
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