Outpatient medication errors and prevention
10.3760/cma.j.issn.1008-5734.2014.06.005
- VernacularTitle:医院门诊用药错误及其防范
- Author:
Yongjiao LIU
1
;
Jing YANG
1
Author Information
1. 100730,首都医科大学附属北京同仁医院药剂科
- Publication Type:Journal Article
- Keywords:
Ambulatory care;
Medical errors;
Safety Management
- From:
Adverse Drug Reactions Journal
2014;(6):341-344
- CountryChina
- Language:Chinese
-
Abstract:
Objective To analyze the status of medication error(ME)of outpatient pharmacy of Beijing Tongren Hospital Affiliated to Capital Medical University and to find effective prevention and control measures. Methods As a pilot run hospital of Beijing Municipal Health Bureau ME monitoring system, ME cases were reported since August 2011 by the hospital and ME reports were analyzed monthly to formulate prevention measures. ME cases of outpatient pharmacy,which were reported to Beijing Municipal Health Bureau,from August 2011 to March 2013 were collected. The ME cases were classified according to the ME classification standard of The National Coordinating Council for Medication Error Reporting and Prevention and the links in which ME cases occurred were analyzed. MEs that occurred from August 2011 to September 2012(the pilot operation stage of the Beijing ME monitoring system)were compared with those from October 2012 to March 2013( the operation stage of Beijing municipal bureau of clinical medication safety monitoring network). The effectiveness of prevention measures was evaluated. Results A total of 506 ME cases,accounting for 0. 031%(506 / 1 636 429)of the number of outpatient prescriptions at the same time,were collected. There were 2 cases of category A( potential error problems),462 cases of category B(errors happened but the drug was not given to patient,or the drug had been given to patient but was not taken),42 cases of category C( patients had used the drug but not be harmed),and none of categories D-I. Among them,459 ME cases occurred in the links of prescriptions by doctors including improper usage and dosage(75. 16% ,345 / 459),improper administration route(12. 64% ,58 / 459), improper drug selection(5. 88% ,27 / 459),taking medication within comtraindication(3. 05% ,14 / 459), imcompatibility(2. 61% ,12 / 459),and improper choice of solvents(0. 65% ,3 / 459). Forty-seven ME cases occurred in the links of dispensing prescriptions by pharmacists including sound alike,look alike, adjacent locations,and so on. Aiming to the links of doctors making prescriptions,a supervision model of" four-grade prescription comment and four-grade feedback" was carried out since October 2012 and the rate of qualified prescriptions was increased effectively. The proportion of ME cases in the links of prescriptions by doctors in all the prescription cases during the same period decreased from 0. 035%(398 / 1 139 613)in the pilot operation stage to 0. 012%(61 / 496 816)in the operation stage. Aiming to the links of dispensing prescriptions by pharmacists,many kinds of measures were carried out to improve the identification of easily confused drugs. The incidence of ME in the links of dispensing prescriptions by pharmacists decreased from 0. 004%(40 / 1 139 613)in the pilot operation stage to 0. 001%(7 / 496 816)in the operation stage. Conclusion The ME cases in outpatient pharmacy of Beijing Tongren Hospital Affiliated to Capital Medical University were mainly category B and C and mostly occurred in the links of prescriptions by doctors. The main type of ME was usage and dosage. The supervision model of " four-grade prescription comment and four-grade feedback" could effectively prevent the ME in the links of prescriptions by doctors.
