Page 7 - 《中国药房》2021年5期

·药事管理·

240例用药错误引发医疗损害责任纠纷的案件分析 Δ

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胡 琳 ，顾佳慧 ，杜浩鑫 ，保 琦 ，于爱晨 ，李 浩 ，范平安 ，聂小燕 ，史录文 ，陈 敬 （1.北京大学药
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学院药事管理与临床药学系，北京 100191；2.北京大学医药管理国际研究中心，北京 100191）
中图分类号 R951 文献标志码 A 文章编号 1001-0408（2021）05-0513-05
DOI 10.6039/j.issn.1001-0408.2021.05.01
摘 要 目的：研究因用药错误引发医疗损害责任纠纷案件的基本特征及用药情况，为相关部门及医务工作者预防或减少用药错
误所致医疗纠纷提供参考。方法：纳入2001年1月至2020年2月北大法宝法律数据库中因用药错误引发的医疗损害责任纠纷案
件240例，对案件的一般情况、损害结局、涉事医院级别、责任判决及赔偿、用药错误类型及药品种类等进行分析。结果：因用药错
误引发的医疗损害责任纠纷占总体医疗损害纠纷案例的25.3％；损害结局以患者死亡比例最高（占68.3％）；主要鉴定方式为医疗
过失司法鉴定（占57.9％）；例均赔偿金额为20.30万元；涉事医院以三级医院为主（占48.8％）；涉案的主要用药错误类型为处方错
误；涉案的主要药品类别为化学药，其中例数排前3位的分类依次是全身用抗菌类药物、全身用糖皮质激素类药物和精神安定类
药物。结论：用药错误引发不良后果是常见的医疗纠纷原因。医疗机构应着力于完善相关制度、流程，加强药学信息化、自动化系
统建设，降低用药错误的发生概率；同时，应重视医院药学人才队伍培养，充分发挥药师的作用，加强对用药错误事件的监测和干
预；最后，国家司法相关部门应不断完善医疗损害责任纠纷案件的解决机制，为医患双方提供合理保障。
关键词 用药错误；医疗损害责任纠纷；用药安全

Analysis of 240 Cases of Medical Damage Liability Disputes Caused by Medication Error
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HU Lin ，GU Jiahui ，DU Haoxin ，BAO Qi ，YU Aichen ，LI Hao ，FAN Ping’an ，NIE Xiaoyan ，SHI Luwen ，
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CHEN Jing （1. Dept. of Pharmaceutical Administration and Clinical Pharmacy，School of Pharmacy，Peking
University，Beijing 100191，China；2. International Research Center of Pharmaceutical Administration，Peking
University，Beijing 100191，China）
ABSTRACT OBJECTIVE：To study general characteristics and medication of medical damage liability disputes cases caused by
medication error， and to provide references for related departments and medical staff for preventing and reducing
medication-induced medical disputes. METHODS：A total of 240 cases of medical damage liability disputes cases caused by
medication error were collected from Peking University’s Fabao Law Database during Jan. 2001 to Feb. 2020，and analyzed in
terms of general situation，damage outcome，level of the hospital involved，liability judgment and compensation，types of
medication error and drug types. RESULTS：medication-related medical damage liability disputes accounted for 25.3％ of overall
medical damage disputes；the most damage result of patients was death （68.3％）；medical negligence forensic appraisal was
conducted as the main appraisal pattern with a proportion of 57.9％ ；the average case compensation was 203，000 yuan；the
hospitals involved were mainly tertiary hospitals（48.8％）；the main type of medication error involved was prescription error；
chemical medicine was mainly involved，of which the top three categories were systemic antibacterial，systemic corticosteroids and
antipsychotics. CONCLUSIONS：ADR caused by medication errors are the common causes of medical disputes. Medical
institutions should focus on improving the relevant systems and processes， strengthen the construction of pharmaceutical
information and automation system，and reduce the probability of medication errors；at the same time，great importance should be
paid to the cultivation of pharmaceutical talents in hospital，give full play to the role of pharmacists，and strengthen the monitoring
and intervention of medication errors. Finally，the relevant national judicial departments should constantly improve the settlement
mechanism of medical damage liability disputes to provide reasonable protection for both doctors and patients.
KEYWORDS Medication error；Medical damage liability dispute；Medication safety

用药错误（Medication error）是指合格药品在临床使
Δ 基金项目：国家自然科学基金资助项目（No.71874006）
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用全过程中出现的、任何可以防范的用药不当 。用药
＊博士研究生。研究方向：医药政策、合理用药。电话：010-
错误可发生于处方（医嘱）开具与传递，药品储存、调剂
82805019。E-mail：michelle_hlin@pku.edu.cn
# 通信作者：讲师，博士。研究方向：医药政策与法律。电话： 与分发，药品使用与监测，用药指导及药品管理、信息技
[2]
010-82801701。E-mail：jingchen@bjmu.edu.cn 术等药品使用过程中的多个环节 。用药错误严重威胁
中国药房 2021年第32卷第5期 China Pharmacy 2021 Vol. 32 No. 5 ·513 ·