Annual report of National Monitoring Network for Clinical Safe Medication (2023)
10.3760/cma.j.cn114015-20240617-00454
- VernacularTitle:全国临床安全用药监测网年度报告（2023年）
- Author:
Qingxia ZHANG
1
;
Siyan LI
;
Xiangrong BAI
;
Zimin WANG
;
Suying YAN
;
Yuqin WANG
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
2024;26(7):390-398
- CountryChina
- Language:Chinese
-
Abstract:
In 2023, a total of 27 742 cases of medication error (ME) from 439 hospitals in 27 provincial administrative regions were collected in the National Monitoring Network for Clinical Safe Medication. Among them, 282 (1.02%) were classified as grade A, 22 452 (80.93%) as grade B, 4 239 (15.28%) as grade C, 499 (1.80%) as grade D, 141 (0.51%) as grade E, 127 (0.46%) as grade F, 1 (<0.01%) as grade G, and 1 (<0.01%) as grade I; no MEs of grade H occurred. Among the 27 460 patients involved in MEs of grade B to I, 15 131 (55.10%) were male and 12 329 (44.23%) were female; their ages were from 1 day to 103 years; 3 198 (11.65%) were children (<18 years old), 12 576 (45.80%) were young and middle-aged adults (≥18 to <60 years old), and 11 686 (42.56%) were elderly (≥60 years old). The top 3 contents of ME were wrong drug class (5 880 cases, 20.97%), wrong dosage (4 668 cases, 16.65%), and wrong administration frequency (3 184 cases, 11.35%). A total of 270 patients were involved in severe MEs (grade E-I), including 140 (51.85%) males and 130 (48.15%) females, aged from 52 days to 94 years, of which 31 (11.48%) were children, 91 (33.70%) were young and middle-aged adults, and 148 (54.82%) were elderly. The top 3 drugs involved were cefoperazone sodium and sulbactam sodium, metformin, and estazolam. One fatal ME was caused by mistakenly orally taking Fufang Jingjie for fumigation and washing. Among the 27 460 grade B-I MEs, 19 655 (71.58%) were triggered by physicians, 5 688 (20.71%) by pharmacists, and few by nurses, patients and their family members, etc. These MEs mainly occurred in clinics (10 537 cases, 38.37%), in hospital wards (8 187 cases, 29.81%), and in pharmacies (6 470 cases, 23.56%). But among the 270 severe MEs, 121 (44.81%) occurred in the patient′s home. The top 3 persons who discovered the ME were pharmacists (20 693 cases, 74.46%), patients and their family members (3 240 cases, 11.66%), and physicians (2 214 cases, 7.97%). The top 3 factors causing ME were lack of related pharmacologic knowledge (9 382 cases, 28.3%), tiredness (5 974 cases, 18.05%), and insufficient training of medical workers (3 831 cases, 11.58%). In view of MEs with high incidence or more severe in 2023, relevant risks should be paid attention to, including misusing external drugs for internal use, ingestion of drug packaging by mistake, wrong dose conversion in children, ME in special dosing frequency, too fast infusion speed of enteral nutrition preparations and irritant intravenous preparations, interaction between montmorillonite powder and other drugs, hypernatremia caused by fosfomycin sodium, etc. In addition, strengthening the management of drug varieties with frequent severe MEs and fatal MEs, as well as the popular science and safe drug use education for patients, can help ensure the medication safety of patients.
