Annual report of National Monitoring Network for Clinical Safe Medication (2022)
10.3760/cma.j.cn114015-20230608-00421
- VernacularTitle:全国临床安全用药监测网年度报告（2022年）
- Author:
Qingxia ZHANG
1
;
Xiangrong BAI
1
;
Zimin WANG
1
;
Suying YAN
1
;
Yuqin 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:
Medication errors;
Patient safety;
Safety management;
Annual report;
National Monitoring Network for Clinical Safe Medication
- From:
Adverse Drug Reactions Journal
2023;25(7):389-397
- CountryChina
- Language:Chinese
-
Abstract:
In 2022, a total of 22 868 cases of medication error (ME) from 315 hospitals in 26 provincial administrative regions were collected in the National Monitoring Network for Clinical Safe Medication. The number of hospitals reporting ME increased by 14.55% compared with that in 2021 (275 hospitals), and the number of reported ME cases increased by 16.76% compared with that in 2021 (19 585 cases). In 22 868 cases of ME reports, 155 (0.68%) were classified as grade A, 18 981 (83.00%) as grade B, 3 076 (13.45%) as grade C, 422 (1.85%) as grade D, 75 (0.33%) as grade E, 156 (0.68%) as grade F, 1 (<0.01%) as grade G, and 2 (0.01%) as grade H; no MEs of grade I occurred. Among the 22 713 patients involved in MEs of grade B to I, 12 668 (55.77%) were male and 10 045 (44.23%) were female; their ages were from 1 day to 102 years; 2 453 (10.80%) were children (<18 years old), 11 374 (50.08%) were young and middle-aged adults (≥18 to <60 years old), and 8 886 (39.12%) were elderly (≥60 years old). A total of 234 patients were involved in serious MEs (grade E-I), including 134 (57.27%) males and 100 (42.73%) females, aged from 4 days to 94 years, of which 37 (15.81%) were children, 83 (35.47%) were young and middle-aged adults, 114(48.72%) were elderly. The serious MEs (grade E-I) mainly occurred in the administration link [74.36% (174/234)]. The 155 grade A MEs did not involve person who triggered the ME and place where ME occurred. Among the 22 713 grade B-I MEs, 17 102 (75.30%) were triggered by physicians, 4 072 (17.93%) by pharmacists, 764 (3.36%) by nurses, 461 (2.03%) by patients and their family members, and 314 (1.38%) by other persons; the proportion of MEs triggered by physicians increased year by year for 4 consecutive years; the triggers of serious MEs were mainly patients and their family members [61.97% (145/234)]. Among these MEs, 9 238 (40.67%) occurred in clinics, 7 183 (31.63%) in hospital wards, 4 620 (20.34%) in pharmacies, 1 063 (4.68%) in pharmacy intravenous admixture services, 213 (0.94%) in the nurse stations, 321 (1.41%) in patients′ home, 6 (0.03%) in the community health service stations, and 69 (0.30%) in other places. Among the 234 severe MEs, 129 (55.13%) occurred in the patient′s home, and the proportions of MEs and serious MEs occurred in the home increased year by year for 4 consecutive years. The top 3 contents of ME were wrong drug class (4 285, 18.40%), wrong dosage (4 115, 17.67%), and wrong administration frequency (2 808, 12.06%). The top 3 persons who discovered the ME were pharmacists (17 575, 74.74%), patients and their family members (2 654, 11.29%), and physicians (1 752, 7.45%). The top 3 factors causing ME were lack of related pharmacologic knowledge (8 665, 31.94%), tiredness (4 249, 15.66%), and insufficient training of medical workers (3 502, 12.91%).
