Analysis on reports of medication errors from 2015 to 2017 in Xiamen Maternal and Child Health Hospital
10.3760/cma.j.issn.1008-5734.2019.05.006
- VernacularTitle:厦门市妇幼保健院2015至2017年用药错误报告分析
- Author:
Yunsong LI
1
;
Min LIN
1
;
Quanyao CHEN
1
;
Lingsong WANG
1
;
Yao CHEN
1
Author Information
1. 厦门大学附属妇女儿童医院/厦门市妇幼保健院药学部 361003
- Publication Type:Journal Article
- Keywords:
Women;
Child;
Maternal-child health centers;
Medication errors
- From:
Adverse Drug Reactions Journal
2019;21(5):339-345
- CountryChina
- Language:Chinese
-
Abstract:
Objective To understand the occurrence and main characteristics of medication errors (ME) in Xiamen Maternal and Child Health Hospital.Methods All the ME reports received by the ME submission system of Xiamen Maternal and Child Health Hospital from January 1,2015 to December 31,2017 were collected,and ME characteristics such as the time of occurrence,classification,grade,drugs involved,and triggering factors were analyzed.On the basis of the 9-level grading method (grade A-Ⅰ),ME were further divided into potential errors (including potential error problems and errors that happened but the drugs were not given to patients) and out-door errors (the wrong drugs had been given to patients).Results A total of 18 944 ME reports were collected,including 12 ME that occurred before the link of prescription and did not involve patients and 18 932 ME that occurred in the link of prescription and various links after the prescription.Of the 18 932 ME,231 were out-door errors,which accounted for 1.22％ of overall ME.A total of 3 553 074 patients (number of registrations)were prescribed in the study period in the hospital and the incidences of overall ME and out-door errors were 0.53％ (18 932/3 553 074) and 0.07‰ (231/3 553 074),respectively.The highest incidences of both the potential errors and out-door errors appeared from 13:00 to 13:59 [21.87‰(1 120/51 248);0.18％(9/51 248)].The top 3 ME classes in the 18 944 ME were prescription errors (77.37％,14 657 ME),dispensing and location errors (17.35％,3 286 ME),and omission and delivering errors (2.22％,421 ME).Of the 18 944 ME,6 (0.03％),18 821 (99.35％),111 (0.59％),and 6 (0.03％) ME were grading as A,B,C,and D,respectively,while none was grading as E-Ⅰ.Personnel factor took the first place [59.65％ (11 301/18 944)] in all the triggering factors of ME,followed by environmental factor [17.71％ (3 355/18 944)].Conclusions The incidence of overall ME in Xiamen Maternal and Child Health Hospital was 0.53％ and most of the ME were not serious,which were no harm to patients.The peak time of the ME occurrence lasted from 13:00 to 13:59.Prescription error was the main type of ME and the main trigger factor was personnel factor.Results of the study could help to develop targeted precautions to reduce the occurrence of ME.
