摘要目的:探讨基于《2011版ISMP医院用药安全自我评估标准（中文版）》（中文版ISMP标准）的用药安全自我评估在提升医院用药安全水平中的作用。方法:比较分析北京医院2018和2020年采用中文版ISMP标准进行用药安全自我评估的主要结果。该评估由中国药理学会治疗药物监测专业委员会药品风险管理学组组织，纳入比较分析的项目为中文版ISMP标准中的10个关键元素、20个核心指标、161个测评项目。每个测评项目依据Likert五级评分法评分，A~E级对应分值分别为0、0、2、3、4分。比较2次评估中的测评项目实际得分和各关键元素百分得分情况，确定2020年评估中获得最大改善（2018年得分为0分、2020年得分为4分）和未得到改善（2020年得分不高于2018年得分）的项目。结果:2020年161个测评项目实际得分明显高于2018年，差异有统计学意义[4（3, 4）比3（2, 4）分， P<0.001]。2020年关键元素Ⅰ（患者信息）、Ⅱ（药品信息）、Ⅴ（药品标准化、储存和分发）项下测评项目的中位百分得分均明显高于2018年[75.5%(50.0%,100%)比100%(100%,100%)， P=0.002；25.0%(0,75.0%)比100%(75.0%,100%)， P<0.001；50.0%(50.0%,100%)比100%(100%,100%)， P=0.003]。2020年评估中，关键元素Ⅳ（药品标签、包装和命名）百分得分与2018年相同，均为100%；其他9个关键元素百分得分均高于2018年，其中关键元素Ⅶ（环境因素、工作流程及人员配备模式）百分得分提高至100%（2018年为94.2%），其他8个关键元素的百分得分为74.3%~97.2%。获得最大改善的测评项目有14个，关键元素Ⅰ、Ⅱ、Ⅴ、Ⅵ（药物治疗设备的采购、使用和监控维护）和Ⅷ（员工能力与教育）项下分别有1、7、3、2、1个；未得到改善的测评项目24个，关键元素Ⅰ、Ⅱ、Ⅴ、Ⅷ、Ⅸ（患者教育）和Ⅹ（质量流程和风险管理）项下分别有2、4、2、4、1、11个。 结论:采用中文版ISMP标准进行医院用药安全自我评估，有助于提升医院用药安全水平。

abstractsObjective:To explore the role of medication safety self-assessment according to "2011 ISMP Medication Safety Self Assessment for Hospitals (Chinese version)" (Chinese version of ISMP) in improving the level of medication safety in hospitals.Methods:The main results of medication safety self-assessment conducted by Beijing hospital using the Chinese version of ISMP in 2018 and 2020 were compared and analyzed. The assessment was organized by The Drug Risk Management Group of The Professional Committee of Therapeutic Drug Monitoring in The Chinese Pharmacological Society and the content included in the comparative analysis was 10 key elements, 20 core characteristics, and 161 evaluation items in the Chinese version of ISMP. Each item was scored referring to the Likert′s Five-Level Scoring and the corresponding score of choices A-E was 0, 0, 2, 3, and 4 respectively. The actual scores of the items and the percentage scores of 10 key elements in the 2 self-assessment activities were compared. Items with the greatest improvement (0 score in 2018 and 4 score in 2020) and those with no improvement (the score in 2020 was not higher than that in 2018) were found.Results:The median actual score of 161 items in 2020 were higher than that in 2018 and the difference was statistically significant [4(3, 4) vs. 3(2, 4) scores, P<0.001]. The median percentage scores of items under key elements Ⅰ (patient information), Ⅱ (drug information), Ⅴ (drug standardization, storage, and distribution) were significantly higher than those in 2018 [75.5%(50.0%, 100%) vs. 100%(100%,100%), P=0.002; 25.0%(0,75.0%) vs.100%(75.0%,100%), P<0.001; 50.0%(50.0%,100%) vs. 100%(100%,100%), P=0.003) ]. In 2020, the percentage score of key element Ⅳ (drug labeling, packaging, and nomenclature) was 100%, the same as that in 2018; the percentage scores of the other 9 key elements were higher than those in 2018. Among them, the percentage score of key element Ⅶ (environmental factors, workflow, and staffing patterns) increased to 100% (94.2% in 2018) and those of the other 8 key elements were from 73.4% to 97.2%. There were 14 items with the greatest improvement and 1, 7, 3, 2, and 1 item of them was under key elements Ⅰ, Ⅱ, Ⅴ, Ⅵ (medication device acquisition, use, and monitoring), and Ⅷ (staff competency and education), respectively. However, there were 24 items that had not been improved and 2, 4, 2, 4, 1, and 11 items of them were under key elements Ⅰ, Ⅱ, Ⅴ, Ⅷ, Ⅸ (patient education), and Ⅹ (quality process and risk management), respectively. Conclusion:Using the Chinese version of ISMP in self-assessment of medication safety in hospital will help improve the level of hospital medication safety.