| 摘要: |
| 目的：通过对1例因输注高浓度氯化钾的用药错误案例进行全程描述，探讨用药错误的应对和防范措施。方法：通过调查事件的起因、经过、处置、病例回查以及事后处理，提出有效的救治以及用药错误防范措施。结果：该不良事件属于用药错误第三层级的F级至H级。该不良事件救治及时到位，最大限度地降低了用药错误的伤害。结论：通过完善并落实相关制度、加强安全用药教育、加强信息系统建设以及合理的岗位配置可以有效防范用药错误的发生。 |
| 关键词: 用药错误 高钾血症 高警示药品 |
| DOI：doi:10.13407/j.cnki.jpp.1672.108X.2020.12.014 |
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| 基金项目: |
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| A Case of Hyperkalemia Induced by Medication Errors |
| Ma Yuejing |
| ((Beijing Tongzhou Maternal and Child Health Hospital, Beijing 101100, China)) |
| Abstract: |
| Objective: To probe into the countermeasures and preventive measures of drug error through the full description of a case of medication error induced by infusion of high concentration of potassium chloride. Methods: A investigation into the cause, the process, the disposal, the case-reviewing and the post-processing of this medical accident was performed to provide effective treatment and prevention of medication errors. Results: The adverse accident was classified as class F to H of the third level of medication errors. The treatment of the adverse event was in time, which minimized the damage induced by medication errors. Conclusion: By improving and implementing relevant systems, strengthening the education of safe medication, reinforcing the construction of information systems and arranging reasonable job allocation, medication errors can be effectively prevented. |
| Key words: medication errors hyperkalemia high-alert medications |
