药疗事故成因分析

摘要

Objective To put forward an effective procedure to prevent the medication incidents by analyzing the cause of it. Methods A retrospective analysis was performed to observe the causes of 23 medication incidents in Shanghai Medical Association from 2003 to 2009. Results The main cause of medication incidents was violation of drug contraindications, followed by improper drug dosage, improper drug compatibility, improper administration route. Conclusion Medical workers and clinicians should pay great importance to the rational use of medicines to prevent medication incident.%目的 通过分析药疗事故成因,提出防范药疗事故的有效措施.方法 回顾性分析2002年9月至2009年12月由上海市医学会判定为药疗事故的23个案例的事故成因.结果 23例事故中,一级事故13例,二级事故2例,三、四级事故各4例.事故原因方面,以违反药物禁忌证或慎用原则构成事故比例为最多(4例),其次为药物剂量过失、药物配伍错误、给药途径不当(各3例).另外,给药时间不当、违反操作规定、用药期间未按规定监测指标、用药适应证不当及其他原因各有2例.结论 医药工作者和临床医师应高度重视合理用药以防范药疗事故的发生.