目的:分析用药错误发生的原因并制定有效防范措施,促进临床合理用药.方法:对绵阳市某三级医院2012-2015年上报的125例用药错误案例进行回顾性分析,运用根本原因分析法找出事件根本原因,并进行描述性分析和χ2检验.结果:从严重程度来看,第二层级(B、C、D级)用药错误占88%,第三层级(E、F、G、H级)用药错误占12%,第一层级(A级)和第四层级(I级)用药错误未发生;药学部第二层级用药错误发生数量较多,第三层级用药错误发生数量较少,与护理部用药错误情况存在统计学差异(P<0.05).从用药错误发生的根本原因来看,系统因素占88.8%,个人因素占11.2%;从用药错误类型来看,以药物品种错误、药物剂量错误、药物规格错误多见;从引发人员来看,以初级技术职称人员多见,但与中高级职称人员相比,差异不具有统计学意义(P>0.05).结论:应从优化工作流程、健全各项制度、加大监管力度、改善工作环境等方面采取措施减少用药错误的发生.%Objective: To analyze the reasons of Medication error (ME) and promote clinical rational drug use.Methods: 125 cases of ME in hospital from 2012 to 2015 were retrospectively analyzed by the root cause analysis method (RCA method).Descriptive statistics and chi square test were used.Results: Proportion of ME in the second degree (class B, C and D) and the third degree (class E,F,G and H) was respectively 88% and 12%.ME with the first degree (class A) and the fourth (class I) have not been reported.There were significant differences of ME in the second and third degree between pharmaceutical department and nursing department (P<0.05).Systematic factors accounted for 88.8% while personal factors accounted for 11.2% in terms of Root Causes of ME.The proportion of drug error, dosage error and standard error were higher.And the ones with primary title related to ME were the most, however the differences of ME induce by the primary title and Intermediate or senior title may be insignificant (P>0.05).Conclusion: It is advisable to optimize workflow, perfect all kinds of systems, strengthen supervision and administration and improve conditions of work so as to reduce the occurrence of ME.
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