Page 112 - 2021年15期

·药师与药学服务·

基于全国临床安全用药监测网的高尿酸血症/痛风患者用药错误

分析 Δ

张青霞 ，张益志 ，曾 艳 ，王育琴 （1.首都医科大学宣武医院药学部，北京 100053；2.首都儿科研究所附属
1 #
1＊
2
1
儿童医院，北京 100020）
中图分类号 R969.3 文献标志码 A 文章编号 1001-0408（2021）15-1894-05
DOI 10.6039/j.issn.1001-0408.2021.15.17

摘 要 目的：了解高尿酸血症/痛风患者用药错误（ME）发生情况及其相关因素，以避免和减少相关不良事件的发生、保障患者
用药安全。方法：从全国临床安全用药监测网调取自2012年9月22日－2020年7月9日期间所有高尿酸血症/痛风相关的ME报
告，并对ME的上报省份、分级与涉及药品、错误内容、引发人员和错误因素等6个方面进行分析。结果：符合纳入要求的共有179
例ME报告，来自11个省市的47家医院，涉及的药品主要包括苯溴马隆（36例，占20.11％）、别嘌醇（31例，17.32％）、碳酸钙D3 （30
例，占16.76％）、转化糖电解质（24例，占13.41％）和碳酸氢钠（22例，占12.29％）。B级ME报告最多（124例，占69.27％）；严重ME
有3例（占1.68％）。错误内容主要为禁忌证，有70例次（占37.43％，主要涉及的药品是碳酸钙D3和转化糖电解质）。引发ME的
人员主要为医师，有 126 例（占 70.39％，引发的主要错误内容是禁忌证）。引发 ME 的主要错误因素是人员因素，有 120 例（占
67.04％，主要是知识欠缺）；其次是环境因素，有33例（主要是设备故障）。结论：高尿酸血症/痛风患者ME主要由降尿酸药物和引
起尿酸变化的非降尿酸药物引起；主要错误内容是禁忌证，多由非降尿酸药物引起，而且多由医师引发；错误因素主要为知识欠缺
和设备故障。建议加强人员培训或者引入临床用药支持决策系统；同时需要关注药物使用过程相关设备的正确使用和维护。
关键词 高尿酸血症；痛风；用药错误；禁忌证；风险防范

Analysis of Medication Errors in Patients with Hyperuricemia/Gout Based on National Monitoring
Network for Clinical Safe Drug Use
2
1
ZHANG Qingxia ，ZHANG Yizhi ，ZENG Yan ，WANG Yuqin（1. Dept. of Pharmacy，Xuanwu Hospital，Capital
1
1
Medical University，Beijing 100053，China；2. Children’s Hospital of Capital Institute of Pediatrics，Beijing
100020，China）
ABSTRACT OBJECTIVE：To investigate the occurrence of medication errors（ME）in patients with hyperuricemia/gout and its
related factors，in order to avoid and reduce the occurrence of related ADE and ensure the safety of drug use in patients.
METHODS：The ME reports related to hyperuricemia/gout were collected from National Monitoring Network for Clinical Safe
Drug Use during Sept. 22nd，2012 to Jul. 9th，2020，and then analyzed in terms of reporting provinces，classification and drugs
involved，error content，initiator and error factors. RESULTS：A total of 179 ME reports，which met inclusion criteria，were
included from 47 hospitals in 11 provinces. The drugs involved mainly included benbromarone（36 cases，20.11％），allopurinol
（31 cases，17.32％），calcium carbonate D3（30 cases，16.76％），inverting sugar electrolyte（24 cases，13.41％）and sodium
bicarbonate（22 cases，12.29％）. Grade B ME were the most frequently reported（124 cases，69.27％）；severe ME occurred in 3
cases（1.68％）. The main errors were contraindications，accounting for 70 cases（37.43％，mainly involving calcium carbonate D3
and inverting sugar electrolyte）. The people who caused ME were mainly doctors，involving 126 cases（70.39％，the main content
of errors was contraindications）. The main error factors for ME were personnel factors，involving 120 cases（67.04％ ，mainly
lacking of knowledge），followed by environmental factors（33 cases，mainly equipment failure）. CONCLUSIONS：ME in patients
with hyperuricemia/gout are mainly caused by uric acid-lowering drugs and non-uric acid-lowering drugs that cause changes in uric
acid. The main error contents include contraindications，which were mostly caused by non-uric acid-lowering drugs and doctors.
The main error factors are lack of knowledge and equipment failure. It is suggested to strengthen personnel training or introduce
clinical medication support decision-making system，while pay
Δ 基金项目：国家重点研发计划（No.2020YFC2008305）；北京市
科技计划项目（No.D181100000218002） attention to the correct use and maintenance of related
＊副主任药师，硕士。研究方向：用药安全、心血管药物治疗管 equipment in the process of drug use.
理。电话：010-83922154。E-mail：Wl7322681@sina.com KEYWORDS Hyperuricemia； Gout； Medication errors；
# 通信作者：主任药师，硕士生导师。研究方向：用药安全、药事 Contraindications；Risk prevention
管理。E-mail：18601061925@163.com

·1894 · China Pharmacy 2021 Vol. 32 No. 15 中国药房 2021年第32卷第15期