藥師自主性通報調劑疏失之相關因素分析－以某區域醫院為例

Abstract

為了病人的用藥安全，調劑疏失一直是各醫事機構藥劑部門管理者戮力改善的重點。本研究目的在分析調劑疏失的發生率、錯誤類型、錯誤原因與錯誤科別，並了解不同相關因素對於調劑疏失的影響。 本研究以回溯性方法，收集自2016年2月至2017年3月北部某區域醫院藥師自主線上通報的門診調劑疏失事件，分析調劑疏失的發生率、錯誤類型、錯誤原因與錯誤科別。總計155件調劑疏失事件納入分析。 研究結果顯示，錯誤類型以「品項配錯」為最大宗，占55.5%，「數量配錯」次之，占27.7%。錯誤原因大部分為「個人因素」，占63.2%，其次為「藥品名稱相似」23.9%。超過一半的調劑疏失事件（55.5%）發生於調劑內科處方時，其次是調劑外科處方14.8%與調劑精神科處方9.0%。處方的藥品品項數與調劑疏失沒有關聯性，呈現不規則的分布。 調劑疏失事件的發生時段以10:01 – 12:00為最多，占41.9%，然而此時段亦為該院處方量最多的時段。調劑時段對調劑疏失有顯著的影響（R2 = 0.69，P= 0.02），呈現負線性關係，隨著調劑時段的改變，調劑疏失總件數也越來越低。 根據研究結果，建議提升通報內容的信效度，以及規劃與執行品管措施，並持續追蹤成效。對於改善調劑品質的建議如下：安排足夠的覆核人力、善用自動化設備與軟硬體的提升。

For patient safety, reducing dispensing errors has been the goal of pharmacy directors in health care organizations. The purpose of this study was to analysis of the incidence, type, causes and medicine division of dispensing errors, and to investigate different associated factors affecting dispensing errors. This was a retrospective study. Data were collected from February 1, 2016 to March 31, 2017. Researching data were collected from self-reporting outpatient dispensing errors by pharmacists in a regional hospital in north Taiwan. A total of 155 data were obtained. It was found that the most common dispensing errors were wrong drug (55.5%) and wrong quantity (27.7%). The most common causes were individual factors (63.2%) and sound-alike drugs (23.9%). Over half of dispensing incidents (55.5%) happened when dispensing prescriptions from the department of internal medicine, 14.8% for department of surgery and 9.0% for department of psychiatry. No association was found between the number of drug dispensed per prescription and dispensing incidents. It showed irregular distribution. Most of dispensing errors (41.9%) happened during the period of 10:01 AM to 12:00 PM. However, most prescriptions were also dispensed during this period. Significant negative linear correlation was found between the time period of dispensing and dispensing incidents. (R2 = 0.69, P= 0.02). According to the above study, it would suggest enhance the reliability and validity of self-reporting information. Plan and implement continuous quality improvement, and keep evaluating effectiveness of actions. For improving quality of dispensing, suggestions are as follows. First, provide sufficient manpower to support verification. Second, use automated dispensing machine. Third, update computer equipment regularly.