Abstract：The National Monitoring Network for Clinical Safe Medication was established in September 2012 by Medication Safety Panel in China Core Group of International Network for the Rational Use of Drugs (INRUD). As of December 31, 2018, a total of 40 873 cases of medication error (ME) were collected. In 2018, 11 761 cases of medication error (ME) from 177 hospitals in 24 provincial administrative regions were reported in China, of which 55 (0.47%) were classified as grade A, 9 419 (80.09%) as grade B, 2 001 (17.01%) as grade C, 179 as grade D ( 1.52%), 69 (0.59%) as grade E, 33 (0.28%) as grade F, 3 (0.02%) as grade G, 2 (0.02%) as grade H, and 0 as grade I; of which a total of 107 cases (0.91%) were determined as serious ME because of leading to patient harm. A total of 11 706 cases of ME (grade B-H) involved patients, including 6 668 males (56.96%) and 5 038 females (43.04%). These patients aged from 1 day to 105 years, of which 1 365 patients (11.66%) aged <18 years, 5 956 patients (50.88%) aged ≥18 to <60 years, and 4 385 patients (37.46%) aged <60 years. The top 3 drugs involved in serious ME were vancomycin hydrochloride, cefoperazone sulbactam, and methotrexate tablets. The 55 cases of class A ME did not involve people who triggered the ME and places where ME occurred in. In the 11 706 cases of class B-H ME, 7 128 (60.89%) were triggered by physicians, 2 920 (24.94%) by pharmacists, 513 (4.38%) by nurses, 124 (1.06%) by patients and their families, and 1 021 (8.72%) by other people; 4 369 (37.32%) occurred in the clinic, 3 625 (30.97%) in the pharmacy, 646 (5.52%) in the pharmacy intravenous admixture services, 230 (1.96%) in the nurse station, 48 (0.41%) at home, 1 (0.01%) in the community health service station, and 178 (1.52%) in other places. The top 3 contents of ME were wrong drug class, wrong total dose, and wrong single dose. The top 3 people who discovered the ME mostly were pharmacists, nurses, and patients and their families. The top 3 factors mainly causing ME were lack of related pharmacologic knowledge of medical staff, tiredness of medical staff, and presence of look alike and sound alike drugs.
张青霞, 王雅崴, 李晓玲, 王育琴, 合理用药国际网络中国中心组临床安全用药组, 中国药理学会药源性疾病学专业委员会. 全国临床安全用药监测网临床安全用药年度报告(2018)[J]. 药物不良反应杂志社, 2019, 21(1): 2-8.
Zhang Qingxia, Wang Yawei, Li Xiaoling, Wang Yuqin, Medication Safety Panel in China Core Group of International Network for the Rational Use of Drugs, Chinese Pharmacological Society Professional. Annual report on clinical medication safety of National Monitoring Network for Clinical Safe Medication (2018). Adverse Drug Reactions Journal, 2019, 21(1): 2-8.
