Analysis on 477 medication error reports of traditional Chinese medicine

Abstract

Objective To investigate the status and influencing factors of medication error (ME) in traditional Chinese medicine. Methods ME reports in Xuanwu Hospital of Capital Medical University from January 1st, 2014 to November 31st, 2014 were collected from International Network for the Rational Use of Drugs (INRUD). Of them, ME reports of traditional Chinese medicine were selected. Category, content, persons who triggered the ME, triggering factor, persons who found the ME were analyzed descriptively. Results A total of 863 ME reports were collected and 477 reports (55.27%) related to traditional Chinese medicine were selected. Of the 477 ME reports, 180 reports(37.74%) were related to Chinese patent drugs and 297 reports (62.26%) were related to Chinese herbal drugs. Four hundred and seventy-seven patients were reported in the 477 ME reports. Of the 477 patients, 218 patients (45.70%) were male, 221(46.33%) were female, and in 38 (7.97%) the sex was not clear. Their ages were from 4 to 92 years and 113 patients(23.69%) were ≥66 years old. Of the 477 MEs, 83 cases (17.40%) belonged to category A, 389 cases(81.55%) belonged to category B, 5 cases(1.05%) belonged to category C, and none of the patients were hurt. The dosage errors in content of MEs ranked the first and accounted for 31.03% (148/477), errors of drug category ranked the second and accounted for 12.16% (58/477). In persons who triggered the ME, doctors accounted for 68.13% (325/477), pharmacists accounted for 23.06% (110/477). Four hundred and sixty-seven cases of the 477 MEs were caused by a factor, 28 cases were caused by 2 kinds of factors, 10 cases were caused by 3 kinds of factors, and a total of 525 person-time MEs were reported. Lack of professional knowledge of traditional Chinese medicine was the first triggering factor and accounted for 24.57%(129/525), fatigue was the second triggering factor and accounted for 17.72%(93/525). The main persons who found the MEs were pharmacists with primary and medium professional titles and accounted for 61.49% (289/470) and 36.81% (173/470), respectively. Conclusions MEs related to traditional Chinese medicine accounted for half of all MEs and most of them were related to Chinese herbal drugs. The main persons who triggered the MEs were doctors and pharmacists. The main triggered factors were lack of professional knowledge of traditional Chinese medicine and fatigue. Pharmacists play an important role to find and correct ME related to traditional Chinese medicine in time for protecting the patient′s medication safety. Key words: Medication errors; Drugs, Chinese herbal; Chinese patent drugs