目的：为临床合理用药提供参考。方法：对我院2014年10月－2015年9月门诊药房报告的用药错误（ME）案例进行分析，包括ME分级、分类、发生原因、发生和发现ME的人员情况及构成比。结果：207例报告中无A级错误，B级错误199例，C级错误8例，无D～I级错误。其中，医师处方错误162例（78.26％），药师调剂错误45例（21.74％），排名前3位的医师处方错误依次为用法用量不当（42.59％）、给药途径不当（40.74％）和溶剂不适宜（5.56％）；排名前3位的药师调剂错误依次为品种错误（40.00％）、规格错误（28.89％）和数量错误（24.44％）。医师处方错误的原因主要是信息系统不完善（56.17％）和医师不了解药物信息（43.83％）；药师调剂错误的主要原因是药品一品多规（35.56％）、名称相似（28.89％）和人员疲劳（26.67％）。发现ME的人员中，药师、护士和患者或家属占比分别为97.58％、1.45％和0.97％。结论：进一步加强医院信息化建设，同时加强医师和药师的在岗培训，可以在一定程度上减少ME的发生。%OBJECTIVE:To provide reference for clinical rational drug use. METHODS:Medication error(ME)cases report-ed from outpatient department from Oct. 2014 to Sept. 2015 in our hospital were analyzed,including ME category,classification, cause and proportion of persons who triggered or detected ME. RESULTS:Among 207 reports,there was no case of category A, 199 cases of category B,8 cases of category C,no of categories D-I. Among them,162 cases occurred in the links of prescrip-tions by doctors (78.26%),45 cases (21.74%) occurred in the links of dispensing prescriptions by pharmacists,the top 3 ME were improper usage(42.59%),improper administration route(40.74%)and inappropriate solvent(5.56%);the top 3 dispensing errors were variety error(40.00%),specification error(28.89%)and number errors(24.44%). The main causes for prescription errors were incomplete information system(56.17%)and drug information missing of doctors(43.83%);the main causes for dis-pensing errors were double specifications of drugs(35.56%),similar drug name(28.89%)and staffsntired(26.67%). In terms of the persons who triggered ME,the proportions of pharmacists,nurses,patients or their families were 97.58%,1.45% and 0.97%, respectively. CONCLUSIONS:Further strengthening information system and the on-the-job training for physicians and pharmacists can reduce the ME to some extent.
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