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目的：分析首都医科大学附属北京同仁医院门诊用药错误（ME）的发生情况，探讨 ME的有效防范措施。方法首都医科大学附属北京同仁医院作为参与北京市卫生局 ME 监测报告系统试运行的医院，自2011年8月上报 ME 报告，并在医院内按月进行 ME 报告分析，根据分析结果制定防范措施。收集门诊药房2011年8月至2013年3月上报北京市卫生局的 ME 报告，进行 ME 分级（按美国国家用药错误报告及预防协调委员会标准）和发生环节分析，分2011年8月至2012年9月（北京市 ME 监测报告系统试运行阶段）和2012年10月至2013年3月（全国临床安全用药监测网络运行阶段）2个时段进行 ME 发生情况比较，评价医院所制定防范措施的有效性。结果共收集到ME 报告506例，占同期门诊处方例数的0.031%（506/1636429）。A 级错误（错误隐患）2例，B 级错误（发生错误但未发给患者，或已发给患者但未使用）462例，C 级错误（患者已使用，但未造成伤害）42例，无 D ~ I 级错误。ME 发生在医师处方环节者459例，主要为用法用量不当（75.16%，345/459）、给药途径不当（12.64%，58/459）、选药不当（5.88%，27/459）、有禁忌证用药（3.05%，14/459）、配伍不当（2.61%，12/459）及溶媒不适宜（0.65%，3/459）；发生在药师调配环节者47例，导致错误的主要原因有名称相似、包装相似及位置相邻等。针对医师处方环节，医院自2012年10月启动“四级点评、四级反馈”的监管模式，有效提高了处方合格率，医师处方环节的 ME 例数占同期处方例数的比例由试运行阶段的0.035%（398/1139613）降至运行阶段的0.012%（61/496816）。针对药师调配环节，采取多种方法提高易混淆药品的辨识度，药师调配环节的 ME 发生率由试运行阶段的0.004%（40/1139613）降至运行阶段的0.001%（7/496816）。结论首都医科大学附属北京同仁医院门诊 ME 以 B 级和 C 级错误为主，主要发生在医师处方环节，主要错误类型为药物用法用量不当。“四级点评、四级反馈”的监管模式可有效防范医师处方环节的 ME。“,”Objective To analyze the status of medication error(ME)of outpatient pharmacy of Beijing Tongren Hospital Affiliated to Capital Medical University and to find effective prevention and control measures. Methods As a pilot run hospital of Beijing Municipal Health Bureau ME monitoring system, ME cases were reported since August 2011 by the hospital and ME reports were analyzed monthly to formulate prevention measures. ME cases of outpatient pharmacy,which were reported to Beijing Municipal Health Bureau,from August 2011 to March 2013 were collected. The ME cases were classified according to the ME classification standard of The National Coordinating Council for Medication Error Reporting and Prevention and the links in which ME cases occurred were analyzed. MEs that occurred from August 2011 to September 2012(the pilot operation stage of the Beijing ME monitoring system)were compared with those from October 2012 to March 2013( the operation stage of Beijing municipal bureau of clinical medication safety monitoring network). The effectiveness of prevention measures was evaluated. Results A total of 506 ME cases,accounting for 0. 031%(506 / 1 636 429)of the number of outpatient prescriptions at the same time,were collected. There were 2 cases of category A( potential error problems),462 cases of category B(errors happened but the drug was not given to patient,or the drug had been given to patient but was not taken),42 cases of category C( patients had used the drug but not be harmed),and none of categories D-I. Among them,459 ME cases occurred in the links of prescriptions by doctors including improper usage and dosage(75. 16% ,345 / 459),improper administration route(12. 64% ,58 / 459), improper drug selection(5. 88% ,27 / 459),taking medication within comtraindication(3. 05% ,14 / 459), imcompatibility(2. 61% ,12 / 459),and improper choice of solvents(0. 65% ,3 / 459). Forty-seven ME cases occurred in the links of dispensing prescriptions by pharmacists including sound alike,look alike, adjacent locations,and so on. Aiming to the links of doctors making prescriptions,a supervision model of“ four-grade prescription comment and four-grade feedback” was carried out since October 2012 and the rate of qualified prescriptions was increased effectively. The proportion of ME cases in the links of prescriptions by doctors in all the prescription cases during the same period decreased from 0. 035%(398 / 1 139 613)in the pilot operation stage to 0. 012%(61 / 496 816)in the operation stage. Aiming to the links of dispensing prescriptions by pharmacists,many kinds of measures were carried out to improve the identification of easily confused drugs. The incidence of ME in the links of dispensing prescriptions by pharmacists decreased from 0. 004%(40 / 1 139 613)in the pilot operation stage to 0. 001%(7 / 496 816)in the operation stage. Conclusion The ME cases in outpatient pharmacy of Beijing Tongren Hospital Affiliated to Capital Medical University were mainly category B and C and mostly occurred in the links of prescriptions by doctors. The main type of ME was usage and dosage. The supervision model of “ four-grade prescription comment and four-grade feedback” could effectively prevent the ME in the links of prescriptions by doctors.