【摘要】 目的 分析居家用药错误发生的原因及特点，探讨如何减少居家用药错误的发生。方法 检索国内外数据库(截至2021年9月1日),收集居家用药环节严重用药错误病例报告类文献，记录患者的性别、年龄、用药错误涉及药物、错误内容、错误因素、错误级别等，进行统计分析。结果 共收集到73篇居家严重用药错误报告，涉及76例患者。男33例(43.42%),女43例(56.58%);年龄22 d～87岁；儿童(<18岁)24例(31.58%),老年人(≥60岁)32例(42.11%);用药错误级别E级10例、F级50例、G级3例、H级7例、I级6例；错误内容主要为品种错误、用量错误、频次错误，分别为28例、26例、12例；引发用药错误的因素主要为人员因素、药品因素、环境因素，分别为64例、17例、5例；涉及高警示药品23例，慢性疾病用药13例。结论 防范居家用药错误需要医务工作者、患者及其家属共同参与。通过药师与医护协作开展院外延伸的、连续的、居家的药学服务等措施，可提高患者用药依从性以及安全用药认知能力，从而避免居家用药错误的发生，保证患者居家用药安全。更多还原

【Abstract】 Objective To analyze the causes and characteristics of home medication errors, and discuss how to reduce the occurrence of home medication errors.Methods Domestic and international databases(as of September 1,2021) were searched to collect literature in the category of serious medication error case reports in home medication, and the patient′s gender, age, drugs involving medication errors, error content, error factor, and error level were recorded for statistical analysis.Results A total of 73 reports on serious medication errors at home were collected, involving 76 patients; among the 76 patients, 33(43.42%) were male and 43(56.58%) were female; their ages ranged from 22 days to 87 years, 24(31.58%) were children(<18 years old) and 32(42.11%) were elderly(≥60 years old).There were 10 cases in category E,50 cases in category F,3 cases in category G,7 cases in category H and 6 cases in category I of medication errors; the error contents were mainly variety error(n=28),dosage error(n=26) and frequency error(n=12);the factors triggering medication errors were mainly personnel factors(n=64),drug factors(n=17) and environmental factors(n=5);there were 23 cases involving high alert medicines and 13 cases of chronic disease medication.Conclusion The involvement of healthcare professionals, patients and their families is needed to prevent medication errors at home.Through pharmacists working with doctors and nurses to provide extended out-of-hospital, continuous, home pharmacy services and other measures to improve patients′ medication compliance and safe medication cognition, the occurrence of medication errors at home can be prevented and the safety of patients′ home medication can be ensured.更多还原