Analysis of Medication Errors in Patients with Hyperuricemia/Gout Based on National Monitoring Network for Clinical Safe Drug Use / 中国药房

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 D 3（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 D 3 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 attention to the correct use and maintenance of related equipment in the process of drug use.