目的：研究临床药物治疗中用药错误的分布特点，为制定用药错误风险管理持续改进方案提供参考。方法：采用问题病案回顾统计分析方法，对甘肃省第二人民医院2013年6月-2014年5月住院各病区疑似用药错误的各类记录和数据进行分析。结果：统计显示，疑似用药错误共计1586例，主要存在于医生、护士、药师及患者4个方面，构成比分别是49.31%、40.04%、9.45%、1.2%；用药错误以B级错误占首位（44.07%）。医生处方环节中选药错误、用量错误和用法错误分别占63.42%、13.17%、12.66%；护士给药环节中给药错误49.6%，药品储存错误30.71%，配药错误10.24%；药师发药环节中，品种错误34%，分剂量错误32%，数量错误30%；患者用法错误占73.68%。结论：用药错误作为临床药物治疗风险的重要组成部分，发生在临床药物治疗过程的各个环节，尤其是医生处方环节和护士给药环节。医疗机构应该建立完善的用药错误监测和报告系统，充分利用药学技术服务和前瞻性的自动化信息干预预警技术，提高用药错误的风险管理水平，制定用药错误风险管理的持续改进指引，保障患者用药安全。
Objective: To understand the distribution features of the medication errors in clinical drug therapy, and to provide references for the development of a program to continuously improve the risk management of medication errors. Methods: A retrospectively statistical analysis of medical records was performed by collecting all kinds of records and data about suspected medication errors in every ward of our hospital from June 2013 to May 2014. Results: A total of 1586 cases of suspected medication errors were analyzed. The medication errors have occurred among the doctors, the nurses, the pharmacists and the patients, and the constituent ratios were The medication errors occur in all aspects of clinical drug treatment, especially by doctors and nurses. Medical institutes should establish monitoring and reporting system of medication errors, improve the level of risk management of medication errors by making full use of pharmaceutical technology services as well as automatic information technology for early warning and intervention, and formulate guidelines for continuous improvement of risk management of medication errors so as to ensure patients medication safety. 49.31%, 40.04%, 9.45% and 1.2% respectively. Class B errors accounted for the first place of the medication errors (44.07%). Wrong drug, wrong dosage and wrong drug usage in doctors' prescription accounted for 63.42%, 13.17% and 12.66% respectively; the administration errors, wrong storage and dispensing errors by the nurses accounted for 49.6%, 30.71% and 10.24% respectively. Wrong type, wrong distributing dose and wrong number by the pharmacists accounted for 34%, 32% and 30% respectively. The wrong drug usage by patients accounted for 73.68%. Conclusion: Medication errors are an important part of the clinical risk of drug therapy.
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