A Retrospective Analysis on Medication Error Monitoring Results in Our Hospital in Five Years / 中国药师

ABSTRACT

Objective: To explore the potential risks in hospital medication management system and propose the preventive meas-ures. Methods: The medication error (ME) cases reported from Jan 1st2012 to Dec 31st2016 in our hospital were retrospectively ana-lyzed in terms of ME category, classification, occurrence link, cause, influencing factors, detecting person and the proportion of high-alert medication MEs. Results: A total of 425 ME reports were collected, and among them, 311 cases were related to western medi-cines (73. 18% ), and 114 cases were related to traditional Chinese medicines (26. 82% ). The proportion of ME in category A, B and C was 4. 24% , 89. 65% and 5. 41% , respectively; the proportion of ME in category D, E and F was 0. 24% . ME in category G, H and I was not reported. In terms of the ME classification, the proportion of drug variety error was the highest (23. 29% ) followed by the repeated medication error (9. 41% ) and the dosage error (8. 94% ). As for the ME occurrence link, the proportion of prescription error was the highest (73. 18% ) followed by the dispensing error (16. 94% ). The top factor to trigger ME was lack of knowledge (26. 82% ) followed by the similar drug name (21. 41% ). The main person who detected ME was pharmacists (93. 88% ). Among of the 425 ME reports, 81 cases were related to high-alert medication, and the top two were insulin errors (48. 15% ) and oral hypoglyce-mic agents errors (23. 46% ). Conclusion: It can partly prevent ME by improving selection and management of new drugs, improving drug information system, enhancing drug quality management and strengthening safe medication knowledge education.