Song L, Chui W C M, Lau C P, Cheung B M Y
Department of Medicine, University of Hong Kong, Hong Kong, China.
J Clin Pharm Ther. 2008 Apr;33(2):109-14. doi: 10.1111/j.1365-2710.2007.00880.x.
Inappropriate medication use may harm patients. We analysed medication incident reports (MIRs) as part of the feedback loop for quality assurance.
From all MIRs in a university-affiliated acute general hospital in Hong Kong in the period January 2004-December 2006, we analysed the time, nature, source and severity of medication errors.
There were 1278 MIRs with 36 (range 15-107) MIRs per month on average. The number of MIRs fell from 649 in 2004, to 353 in 2005, and to 276 in 2006. The most common type was wrong strength/dosage (36.5%), followed by wrong drug (16.7%), wrong frequency (7.7%), wrong formulation (7.0%), wrong patient (6.9%) and wrong instruction (3.1%). 60.9%, 53.7% and 84.0% of MIRs arose from handwritten prescription (HP) rather than the computerized medication order entry in 2004, 2005 and 2006 respectively. In 43.1% of MIRs, preregistration house officers were involved. Most errors (80.2%) were detected before any drug was wrongly administered. The medications were administered in 212 cases (19.7%), which resulted in an untoward effect in nine cases (0.8%).
The most common errors were wrong dosage and wrong drug. Many incidents involved preregistration house officers and HPs. Our computerized systems appeared to reduce medication incidents.
用药不当可能会对患者造成伤害。我们分析了用药事件报告（MIRs），将其作为质量保证反馈环节的一部分。
从香港一所大学附属医院在2004年1月至2006年12月期间的所有用药事件报告中，我们分析了用药错误的时间、性质、来源和严重程度。
共有1278份用药事件报告，平均每月36份（范围为15 - 107份）。用药事件报告的数量从2004年的649份降至2005年的353份，再降至2006年的276份。最常见的类型是错误的剂量/强度（36.5%），其次是错误的药物（16.7%）、错误的频率（7.7%）、错误的剂型（7.0%）、错误的患者（6.9%）和错误的医嘱（3.1%）。在2004年、2005年和2006年，分别有60.9%、53.7%和84.0%的用药事件报告源自手写处方（HP）而非计算机化的用药医嘱录入。在43.1%的用药事件报告中，预注册住院医生参与其中。大多数错误（80.2%）在任何药物被错误给药之前就被发现了。有212例（19.7%）进行了药物给药，其中9例（0.8%）导致了不良后果。
最常见的错误是剂量错误和药物错误。许多事件涉及预注册住院医生和手写处方。我们的计算机系统似乎减少了用药事件。
