采用上下文、模态和心理学分类法对我院用药错误的回顾分析

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Abstract

Objective To understand the basic situation and causes of medication error (ME) in our hospital and put forward preventive measures, so as to provide reference for hospital medication management.Methods A retrospective analysis of the ME monitoring report reported by our hospital from April 2012 to July 2018 to the international network rational use of drug, China central group clinical safety drug monitoring network was conducted, the error factors, error content, error classification and location were extracted, and contextual, modal and psychological classification was made according to the occurrence and the drugs involved.Results There were 687 cases of ME from April 2012 to July 2018, and the top 3 categories were the central nervous system (14.39%), anti-tumor drugs (13.66%) and hormones and related medications (11.45%).There were 158 cases of ME involved high-alert medications, most of which were insulin(36.71%) and parenteral or oral chemotherapy medication (25.32%).Pharmacists (81.22%) were the main discoverers of ME.ME mainly occurred in dispensing stage(87.77%),and the main contributing factors were look alike and sound alike(42.62%), followed by inadequate review (22.22%) and fatigue (13.27%).And there were mainly action-based (45.11%)and memory-based (30.85%) errors in dispensing stage.The main factor leading to ME in the prescribing stage was lacking knowledge (65.79%).Conclusion Through monitoring and reporting ME, the causes of ME can be continuously discovered and understood.In addition, it′s of great significance for patients′ medication safety to improve the medical staff′s cognition of ME and strengthen the training of pharmacists in checking prescription.

Key words： Medication error Hospital medication management Psychological classification

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	CHEN Xue
	LI Xin-yu
	QIU Feng

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CHEN Xue,LI Xin-yu,QIU Feng. Retrospective analysis of medication errors in our hospital using contextual, modal and psychological classification[J]. 中国当代医药, 2020, 27(20): 188-192.

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http://dangdaiyiyao.com/EN/ OR http://dangdaiyiyao.com/EN/Y2020/V27/I20/188

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