Analysis of the reasons for medication errors in deslanoside injection use
10.3760/cma.j.cn114015-20250117-00037
- VernacularTitle:去乙酰毛花苷注射液用药错误原因分析
- Author:
Siyan LI
1
;
Qingxia ZHANG
Author Information
1. 首都医科大学宣武医院药学部，国家老年疾病临床医学研究中心，北京 100053
- Publication Type:Journal Article
- Keywords:
Deslanoside;
Cardiac Glycosides;
Medication errors;
High-alert medication;
Medication safety;
National Monitoring Network for Clinical Safe Medication
- From:
Adverse Drug Reactions Journal
2025;27(11):654-659
- CountryChina
- Language:Chinese
-
Abstract:
Objective:To explore the causes of medication errors (ME) associated with deslanoside injection and put forward targeted preventive recommendations.Methods:ME reports related to deslanoside injection in the National Monitoring Network for Clinical Safe Medication (Monitoring Network) as of August 31, 2024 were collected, and sever ME cases of deslanoside injection were also collected though searching medical literature databases at home and abroad, China Judgements Online, and PKULAW database at the same period. The level of severity, occurrence link, error content, occurrence place, trigger personnel and patient outcomes of the MEs were retrospectively analyzed.Results:The Monitoring Network received a total of 41 ME reports of deslanoside injection from September 2012 to August 2024, and the number of reports showed an upward trend year by year. These MEs were classified as grade A in 1 case (2.4%), grade B in 18 cases (43.9%), grade C in 17 cases (41.5%), grade D in 4 cases (9.8%), and grade F in 1 case (2.4%). There were 63.4% (26/41) of MEs occurring in the prescription/doctor′s order prescribing and delivery links, mainly caused by physicians, and the common error contents included solvent errors, medication under contraindications, and having drug-drug interactions. In addition, 26.8% (11/41) of MEs occurred in the drug dispensing and distribution link, and 9.8% (4/41) occurred in the administration and monitoring links. A total of 4 severe MEs of deslanoside injection were collected from the Monitoring Network, medical literature and judicial cases, all of which occurred in the prescription/doctor′s order prescribing and delivery links. Among the 4 severe MEs, 2 ME cases of grade I occurred due to incorrect usage and dosage, resulting in patient death; 1 ME case of grade F was caused by interaction with traditional Chinese medicine, resulting in digitalis poisoning, and another case of grade F was that deslanoside injection was administered to a patient with digitalis poisoning (medication under contraindications).Conclusions:MEs of deslanoside injection often occurs in the prescription/doctor′s order prescribing and delivery links, mainly because of insufficient knowledge of doctors to the drug instructions. It is suggested to strengthen learning and training of medical staff centered around drug instructions, and improve the system interception and process management, so as to improve the medication safety.
