陈　灿，马丽萍，吝战权，张　蕾，2，沈司京#(.北京大学首钢医院药剂科，北京　0044； 2.北京大学药学院药事管理与临床药学系，北京　009)



北京大学首钢医院247例处方错误分析及防范措施

陈灿1，2*，马丽萍1，吝战权1，张蕾1，2，沈司京1#(1.北京大学首钢医院药剂科，北京100144； 2.北京大学药学院药事管理与临床药学系，北京100191)

DOI10.14009/j.issn.1672-2124.2016.01.035

摘要目的：减少北京大学首钢医院(以下简称“我院”)门诊专科医师跨科开药所致的处方环节用药错误(以下简称“处方错误”)，保障门诊患者用药的安全性、有效性和经济性。方法：采用回顾性研究方法，对我院2013年处方点评中发现的247例处方错误进行统计、分析。结果：247例用处方错误中，跨科开药现象非常普遍；处方错误的分类中，以给药频次和单次给药剂量错误最为常见，分别占23.9%和22.7%，其次是无适应证或超适应证用药和重复给药，各占13.8%；疗程、药品品种、给药途径、禁忌证和溶剂错误共占总用药错误的19.0%。跨科开药导致的处方错误中，较为常见的依次为禁忌证用药、给药数量、给药时间、给药频次和重复给药错误。结论：跨科开药是导致处方错误和患者伤害的重要原因，医院应采取措施减少跨科开药的发生。

关键词跨科开药； 处方错误； 防范

Analysis and Countermeasures of 247 Cases of Prescription Errors in Peking University Shougang Hospital

CHEN Can1，2, MA Liping1, LIN Zhanquan1, ZHANG Lei1，2, SHEN Sijing1(1.Dept.of Pharmacy, Peking University Shougang Hospital, Beijing 100144, China; 2.Dept.of Pharmaceutical Administration and Clinical Pharmacy, School of Pharmaceutical Sciences of Peking University, Beijing 100191, China)

ABSTRACTOBJECTIVE：To reduce the prescription medication errors(hereinafter referred to as “prescription errors”) that caused by interdisciplinary prescriptions from the specialists in the outpatient department of Peking University Shougang Hospital (hereinafter referred to as “our hospital”), and to ensure the safe, effective and economic medication in outpatients. METHODS: Retrospective analysis was adopted to conduct statistical analysis on 247 cases of prescription errors that found in the prescription review of our hospital in 2013. RESULTS: Of the 247 cases of prescriptions errors, interdisciplinary prescriptions were very common phenomenon. Dosing frequency errors and single dose errors took the lead of prescription errors classification, respectively accounting for 23.9% and 22.7%; followed by no indications for medication or over indications, and repeated administration, each accounting for 13.8%; the treatment course, drug varieties, route of administration, contraindication and solvent errors totally took up 19.0% of total medication errors. Of the interdisciplinary prescriptions errors, it was quite common to see, in turn, contraindications medication, dosing quantity, dosing time, dosing frequency and repeated administration. CONCLUSIONS: Interdisciplinary prescriptions were the essential cause for the prescription errors and patients’ damage, the hospital should take measures to reduce the occurrence of interdisciplinary prescriptions.

KEYWORDSInterdisciplinary prescriptions; Prescription errors; Prevention

用药错误是指药品在临床使用及管理过程中出现的任何可以防范的用药疏失，这些疏失可导致患者发生潜在的或直接的损害[1]。用药错误可发生在药品使用和管理过程的任何阶段，包括处方环节、处方转录环节、处方调配环节以及给药环节等[2]，而处方环节的用药错误(即处方错误)占用药错误的大多数[3]。……