住院患者药物过敏和皮试相关用药差错的回顾性分析

Retrospective Analysis of Medication Errors Related with Drug Allergy and Skin Test Among Inpatients

关键词:  用药差错  近似错误  不良事件  药物过敏  皮试  药事干预

Key words:  medication errors  near misses  adverse events  drug allergy  skin test  pharmaceutical intervention

摘要:

目的 了解住院患者药物过敏和皮试相关用药差错的发生情况，并考察综合干预的成效。方法 查阅2014-2017年药师医嘱审核拦截登记记录、护理部给药差错呈报系统以及医院质管办用药差错在线无责呈报系统，进行数据汇总、分析，结合质量改进措施进行讨论。结果 药物过敏和皮试相关的近似错误例数逐年下降，与出院人次的比值从2014年的0.277 3%下降到2017年的0.116 4%（P=0.000 0），在年度近似错误中的占比从2014年的8.82%下降到2017年的2.12%（P=0.000 0）；药物过敏和皮试相关的不良事件例数总体呈下降趋势，与出院人次的比值从2014年的0.016 3%下降到2017年的0.005 9%（P=0.009 7）。近似错误涉及的前10位药物包括参麦注射液、胸腺法新、帕瑞昔布、阿莫西林、哌拉西林钠他唑巴坦钠、头孢呋辛钠、头孢替安、拉氧头孢钠、痰热清注射液、阿莫西林克拉维酸钾、头孢哌酮舒巴坦（并列第10）。不良事件涉及的药物包括β-内酰胺类抗菌药、与磺胺类交叉过敏相关的药物、氟喹诺酮类、维生素B1、胸腺五肽、鲑降钙素、蔗糖铁、复方碘口服溶液。结论 医师、药师、护士、信息工程师和质量管理人员团队合作的药事综合干预措施可有效降低药物过敏和皮试相关的用药差错。

Abstract:

OBJECTIVE To investigate the distribution and effectiveness of interventions toward medication errors related with drug allergy and skin test among inpatients. METHODS Records during 2014-2017 were aggregated and analyzed by utilizing inappropriate physician orders documented by auditing pharmacists, medication administration errors derived from nursing administration system and medication errors derived from an online no-fault reporting system. Quality improvement measures were discussed. RESULTS The total number of related near misses decreased year by year, with the ratio of the number of near misses to discharged patients reducing from 0.277 3% to 0.116 4% (2014 vs 2017, P=0.000 0) and relative proportion of annual near misses decreasing from 8.82% to 2.12% (2014 vs 2017, P=0.000 0); the ratio of the number of adverse events to discharged patients decreased from 0.016 3% to 0.005 9% (2014 vs 2017, P=0.009 7). The top 10 medications related with near misses included Shenmai injection, thymosin, parecoxib, amoxicillin, piperacillin sodium/tazobactam sodium, cefuroxime sodium, cefotiam, latamoxef, Tanreqing injection, amoxicillin clavulanate potassium, cefoperazone/sulbactam (juxtaposition tenth). Adverse events involved β-lactams, sulfanilamides, fluoroquinolones, vitamine B1, thymopentin, salmon calcitonin, iron sucrose and Compound Iodide solution. CONCLUSION Comprehensive interventions by collaboration among physicians, pharmacists, nurses, information engineers and quality management staff can effectively reduce the occurrence of medication errors related with drug allergy and skin test.