目的：为减少乃至杜绝门诊高危药品的用药错误提供参考。方法：收集2013－2014 年我院门诊处方点评中发现的高危

药品用药错误，对用药错误的类型、差错级别和引发差错的因素等进行回顾性分析。结果：2 年共点评处方670 997 张，发现用药

错误501 例，其中高危药品的用药错误26 例，包括胰岛素给药途径错误7 例、口服降糖药重复用药和给药剂量错误各1 例、阿片类

药品和非甾体抗炎药重复用药6 例、氨酚待因适应证错误2 例、葡萄糖注射液规格错误和适应证错误各1 例、利多卡因给药途径错

误2 例、甲氨蝶呤给药频率错误2 例、地高辛给药剂量错误2 例、华法林给药剂量错误1 例。医师处方错误，经药师审核发现错误并

拒绝调配的18 例，占69.2％；医师处方错误而药师未发现的8 例，占30.8％。结论：门诊高危药品的用药错误主要发生在医师处方

环节，主要原因为电子医嘱系统没有实行强制和约束策略。提高门诊高危药品安全用药水平需要找到差错环节并采取靶向性安

全用药方案。

OBJECTIVE：To provide reference for reducing and avoiding medication errors of high-alert drugs in outpatient department.

METHODS：The medication errors of high-alert drugs in outpatient prescriptions were collected from our hospital during

2013-2014，and then analyzed retrospectively in terms of the type and degree of medication error，caused factors of medication errors，

etc. RESULTS：670 997 prescriptions were checked in two years，and 501 medication errors were found，including 26 medication

errors of high-alert medication. There were 7 incorrect route of administration of insulin，1 repeated medication and 1 incorrect

dose of oral hypoglycemic agents，6 repeated administration of opioid drugs and non steroidal anti-inflammatory drugs，2 indication

error of paracetamol and codeine phosphate，1 specification and 1 indication error of glucose injection，2 route of administration

error of lidocaine，2 administration frequency errors of methotrexate，2 dose error of digoxin and 1 dose error of warfarin；18

doctors’prescribing errors were found by pharmacists’prescription audit，accounting for 69.2％ ；8 doctors’prescribing errors

were not found by pharmacists’prescription audit，accounting for 30.8％. CONCLUSIONS：Medication errors of high-alert drugs

occur mainly in the prescription segment，and the main reason is that the electronic prescription system lack of compulsory strategy

and policy constraints. Improvement of safety administration of high-alert drugs need to find the error link and adopt targeted medication

safety practices.