Analysis on reports of medication errors on insulin preparations in National Monitoring Network for Clinical Safe Medication from May 2015 to June 2022
10.3760/cma.j.cn114015-20220817-00753
- VernacularTitle:全国临床安全用药监测网2015年5月至2022年6月胰岛素用药错误报告分析
- Author:
Yan YAN
1
;
Yawei WANG
1
;
Yan ZENG
1
;
Suying YAN
1
;
Yuqing WANG
1
Author Information
1. 首都医科大学宣武医院药学部，北京 100053
- Publication Type:Journal Article
- Keywords:
Insulin;
Medication errors;
Safety management;
Monitoring network
- From:
Adverse Drug Reactions Journal
2022;24(11):564-570
- CountryChina
- Language:Chinese
-
Abstract:
Objective:To understand and analyze the occurrence of medication error (ME) on insulin preparations and its influencing factors and provide reference for the standard use of insulin preparations.Methods:The ME reports on insulin preparation-related MEs in the National Monitoring Network for Clinical Safe Medication (monitoring network) from May 6, 2015 to June 30, 2022, were collected and information of MEs including drugs involved, grading, error content, the persons who caused and found the errors, and the factors that triggered the errors were analyzed.Results:During the set period, a total of 2 215 ME reports from 193 hospitals in 26 provinces and municipalities in China were collected in the monitoring network. A total of 2 215 patients were involved, including 1 345 males (60.72%) and 870 females (39.28%), aged from 1 to 95 years, with an average age of (52±4) years. Two thousand one hundred and eighty-two MEs (98.51%) were mild and 33 (1.49%) were severe. The 2 215 ME reports involved 8 classes and 29 kinds of insulin, and a total of 2 263 times of ME content. The top 3 ME contents of insulin preparations were variety errors (40.70%, 921), interaction/compatibility errors (18.29%, 414), and dosage errors (9.06%, 205). Among the 2 215 MEs, 58.24% (1 290 MEs) were triggered by physicians, 28.26% (626 MEs) by pharmacists, 6.5% (144 MEs) by patients and their families, 5.6% (124 MEs) by nurses, and 1.40% (31 MEs) by others; 1 741 MEs (78.60%) were detected and intercepted in time, of which 75.70% (1 318) were found by pharmacists, 14.01% (244) by patients/family members, 7.76% (135) by nurses, and 2.53% (44) by physicians. The main factors that caused MEs were lack of knowledge (23.28%, 701), similar drug names (19.36%, 583), fatigue (14.51%, 437), etc.Conclusions:The contents of insulin preparations-related MEs mainly include variety error, interaction/compatibility error, and dosage error. MEs are mainly caused by physicians and mostly discovered and intercepted by pharmacists. Lack of knowledge, similar drug names, and fatigue are the major factors causing MEs.
