中国医院用药评价与分析2026，Vol.26Issue(1)：110-113,4.DOI:10.14009/j.issn.1672-2124.2026.01.022
拉莫三嗪相关用药错误病例报告文献分析
Literature Case Analysis of Lamotrigine-Associated Medication Errors
摘要
Abstract
OBJECTIVE:To investigate the contents,clinical manifestations and outcomes of lamotrigine-associated medication errors.METHODS:Relevant databases at home and abroad(up to Sept.20th,2024)were retrieved and the case reports on lamotrigine-associated medication errors were collected.Patient's basic information,content of medication errors,clinical manifestations and outcomes induced by medication errors.Statistical analysis was conducted by using the Excel software.RESULTS:A total of 47 case reports with lamotrigine-associated medication errors were enrolled,including 60 patients.The content of medication errors included dosage(26 cases,43.3%,including excessive initial dosage or rapid dosage increase,and failure to reduce dosage in time after delivery),drug interactions(22 cases,36.7%),variety of drugs(5 cases,8.3%),and patient identity(7 cases,11.7%).There were 59 cases of harmful medication errors(98.3%),mainly involving adverse outcomes in the skin and soft tissue system(such as Stevens-Johnson syndrome and toxic epidermal necrolysis),the nervous system(such as epileptic seizures,dizziness,and tremors),the blood system(such as leukopenia and neutropenia),and the digestive system(such as elevated aminotransferase levels).The main factors of lamotrigine-associated medication errors included pharmaceutical factors(similar drug names)and personnel factors(insufficient knowledge).CONCLUSIONS:The most common types of lamotrigine-associated medication errors are excessive dosage and drug interaction.The adverse outcomes are observed in multiple systems.More attention should be paid to the dosage and interaction of lamotrigine to ensure the medication safety of patients.关键词
拉莫三嗪/用药错误/病例报告/用药安全Key words
Lamotrigine/Medication error/Case reports/Medication safety分类
医药卫生引用本文复制引用
王彦改,吴静雯,白向荣,张青霞..拉莫三嗪相关用药错误病例报告文献分析[J].中国医院用药评价与分析,2026,26(1):110-113,4.基金项目
国家卫生健康委医院管理研究所医院药学高质量发展研究项目(No.NIHAYS2326) （No.NIHAYS2326）
