Analysis of the Cause and Preventive Measures of 26 Cases of Medication Errors of High-alert Drugs in the Outpatient Prescriptions of Our Hospital
10.6039/j.issn.1001-0408.2015.35.10
- VernacularTitle:我院门诊处方中26例高危药品用药错误的原因分析及防范措施
- Author:
Liping MA
;
Zhanquan LIN
;
Sijing SHEN
- Publication Type:Journal Article
- Keywords:
Outpatient prescription;
High-alert drugs;
Medication errors;
Analysis of the cause;
Preventive measures
- From:
China Pharmacy
2015;26(35):4925-4928
- CountryChina
- Language:Chinese
-
Abstract:
OBJECTIVE:To provide reference for reducing and avoiding medication errors of high-alert drugs in outpatient de-partment. METHODS:The medication errors of high-alert drugs in outpatient prescriptions were collected from our hospital during 2013-2014,and then analyzed retrospectively in terms of the type and degree of medication error,caused factors of medication er-rors,etc. RESULTS:670 997 prescriptions were checked in two years,and 501 medication errors were found,including 26 medi-cation errors of high-alert medication. There were 7 incorrect route of administration of insulin,1 repeated medication and 1 incor-rect dose of oral hypoglycemic agents,6 repeated administration of opioid drugs and non steroidal anti-inflammatory drugs,2 indi-cation error of paracetamol and codeine phosphate,1 specification and 1 indication error of glucose injection,2 route of administra-tion error of lidocaine,2 administration frequency errors of methotrexate,2 dose error of digoxin and 1 dose error of warfarin;18 doctors'prescribing errors were found by pharmacists'prescription audit,accounting for 69.2%;8 doctors'prescribing errors were not found by pharmacists'prescription audit,accounting for 30.8%. CONCLUSIONS:Medication errors of high-alert drugs occur mainly in the prescription segment,and the main reason is that the electronic prescription system lack of compulsory strategy and policy constraints. Improvement of safety administration of high-alert drugs need to find the error link and adopt targeted medi-cation safety practices.
