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完整後設資料紀錄
DC 欄位 | 值 | 語言 |
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dc.contributor.advisor | 陳端容 | |
dc.contributor.author | Jui-Yin Chen | en |
dc.contributor.author | 陳瑞瑩 | zh_TW |
dc.date.accessioned | 2021-06-13T17:05:33Z | - |
dc.date.available | 2005-02-03 | |
dc.date.copyright | 2005-02-03 | |
dc.date.issued | 2005 | |
dc.date.submitted | 2005-01-28 | |
dc.identifier.citation | 1.Abood RR: Errors in pharmacy practice. United States Pharmacist 1996; 21:122-132.
2.Allan EL, Narker KN: Fundamentals of medication error research. American journal of health-system pharmacy 1990; 47:555-71. 3.Allan EL, Relationships among facility design variables and medication errors in a pharmacy (Drug dispensing), DAI-B 1995. 4.American Society of Health System Pharmacists: ASHP guidelines on adverse drug reaction monitoring and reporting. American journal of health-system pharmacy 1995; 52:417-9. 5.American Society of Health-System Pharmacists: Suggested definitions and relationships among medication misadventures, medication errors, adverse drug events, and adverse drug reaction. American journal of health-system pharmacy 1998; 55:165-6. 6.American Society of Hospital Pharmacists: ASHP standard definition of a medication errors. American journal of health-system pharmacy 1982; 39:321. 7.American Society of Hospital Pharmacists: ASHP guidelines on preventing medication errors in hospitals. American journal of health-system pharmacy 1993; 50:305-314. 8.Andrews LB, Lacet 1997; 349(9048): 309-313. 9.ASCP guidelines 2003, Categories of medication error. 10.ASHP, Classification of medical error causes, American journal of health-system pharmacy 1993; Vol. 50, N0. 2. Page 11.Bates DE, Cullen DJ, Laird N, et al: Incidence of adverse events: implications for prevention. JAMA 1995; 274:29-34. 12.Bates DW, Gawande AA, Error in medicine: what have we learned? Annals of Internal Medicine 2000; 132:763-7. 13.Bates DW, Leape LL, Cullen DJ, et al: Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA 1998;280:1311-1316. 14.Bates DW, Spell N, Cullen DJ, et al. The costs of adverse drug events in hospitalized patients. JAMA 1997; 277(4):307-311. 15.Bauman AN et al, Policies on documentation and disciplinary action in hospital pharmacies after a medication error. American journal of health-system pharmacy 2001; 58(12): 1120-1125. 16.Bootman JL,Harrison DL, Cox e. The healthy care of drug-relates morbidity and mortality and mortality in nursing facilities. Arch Intern Med. 1997;157:2089-2096. 17.Brennan TA, Leape LL, Laird NM, et al, Incidence of adverse events and negligence in hospitalized patients. Results from the Harvard Medical Practice Study I. NEJM 1991; 324:370-6. 18.Buchanan TL et al, Illumination and errors in dispensing, American journal of health-system pharmacy 1991; 48:2137-45. 19.Chenier GE, Vogel DP: Medication error prevention guidelines. Pharmacy Practice News 1999, pp 25-28. 20.Davis NM: Initiatives for reducing medication errors: the time is now. American journal of health-system pharmacy 2000; 57: 1487-8. 21.Edgar TA, Lee DS, Cousins DD: Experience with a national medication error reporting program. American journal of health-system pharmacy 1994;51: 1335-8. 22.Etsuko et al, The association between dispensing error factors and behavioral characteristics of pharmacists. Yakugaku Zasshi 2003; 123(5): 357-364. 23.Flynn et al, Impact of interruptions and distractions on dispensing errors in an ambulatory care pharmacy, American journal of health-system pharmacy 1994; 56(13): 1319-1325. 24.Grasha AF, O'Neil M: Cognitive processes in Medication Errors. US Pharm 1996; 21:96-109. 25.Guernsey et al, Pharmacists’ dispensing accuracy in a high-volume outpatient pharmacy service: focus on risk management. Drug Intelligence & clinical pharmacy 1983; 17(10): 742-6. 26.Hartwig SC, Denger SD, Schneider PJ: A severity-indexed, incident-report based medication-error reporting program. American journal of health-system pharmacy 1991; 48:2611-6. 27.Helmreich, Robert L. On error management: lessons from aviation. British Medical Journal 2000; 320(7237): 781-5. 28.Hiatt HH, Bames BA, Brennan TA, et al. Special Report: A Study of Medical Injury and Medical Malpractice.NEJM. 321(7):480, 1989. 29.ISMP Medication Safety Alert 2002; 7(13). 30.Joint Commission on Accreditation of Healthcare Organization . Available http://www.jcaho.org/ 31.Kaushal R, Bates DW, Landrigan C, et al. Medication Errors and adverse drug events in pediatric inpatients. JAMA 2001; 285: 2114-20. 32.Kelly WN: Potential risk and prevention, part 1: fatal adverse drug events. American journal of health-system pharmacy 2001; 58:1317-24. 33.Kelly WN: Potential risk and prevention, part 2: drug induced permanent disabilities. American journal of health-system pharmacy 2001; 58:1325-9. 34.Kelly WN: Potential risk and prevention, part 4: reports of significant drug events. American journal of health-system pharmacy 2001; 58:1406-12. 35.Kessler DA: Introducing MEDWathch. A new approach to reporting medication and device adverse effects and product problems. JAMA 1993; 269:2765-8. 36.Kohn LT, Corrigan JM, Donaldson MS, et al. (Committee on Quality of Health Care in America, Institute of Medicine) To Err is Human: Building a Safer Health System. Washington, D.C.; National Academy Press, 1999. 37.Kohn LT, The Institute of Medicine report on medication error: overview and implications for pharmacy. American journal of health-system pharmacy 2001; 58:63-6. 38.Larry M, Pharmacy Design and workload contribute to dispensing error, Pharmacy times 1996; page 39.Lazarou J, Romeranz BH, Corey PN: Incidence of adverse drug reaction in hospitalized patients. JAMA 1998; 279:1200-5. 40.Leape LL, Brennan TA, Laird N, et al, The nature of adverse events in hospitalized patients. NEJM 1991; 324:377-84. 41.Leape LL, Kabcenell AI, Gandhi TK, et al: Reducing adverse drug events: lessons from a breakthrough series collaborative. Joint Commission Journal on Quality Improvement 2000; 26:321-31. 42.Lesar TS, Briceland L, Stein DS: Factors related to errors in medication prescribing. JAMA 1997; 277:312-317. 43.Lesar TS, Lomaestro BM, Pohl H: Medication-prescribing errors in a teaching hospital. A 9-year experience. Arch Intern Med 1997; 157:1569-1576. 44.Liang BA, Coulson KM. Legal issues in performing patient safety work. Nursing Economics 2002; 20: 118-25. 45.Marcellino K, Kelly WN: Potential risk and prevention, part 3: drug induced threates to life. American journal of health-system pharmacy 2001; 58:1399-405. 46.Nadzam DM. Development of Medication-use Indicators by the Joint Commission on Accreditation of Healthcare Organizations. American journal of health-system pharmacy. 48:1925-1930, 1991. 47.National Patient Safety Foundation (1999).Agenda for Research and Development in Patient Safety. Available http//www.ama.assn.org/med-sci/npsf/research/research.htm. 48.Pedersen CA et al, ASHP national survey of pharmacy practice in acute care setting: Monitoring, patient education and wellness-2000. American journal of health-system pharmacy 2000; 57(23): 2171-2187. 49.Pedersen CA, Schneider PJ: ASHP national survey of pharmacy practice in hospital setting: prescribing and transcribing-2001. American journal of health-system pharmacy 2001; 58:2251-66 50.Pedersen CA, Schneider PJ: Vital signs of quality: medication-use safety. American journal of health-system pharmacy 2001; 58:2249. 51.Phillips J, Beam S, Brinker A, Holquist C, et al: Retrospective analysis of mortalities associated with medication errors. American journal of health-system pharmacy 2001; 58:1835-41. 52.Reason, J. (1990).Human error. New York: Cambridge University Press. 53.Rich DS: A process for interpreting data on adverse drug events: Determining optimal target levels. Clinical Therapeutics 1998; 20(Suppl c): 59-71. 54.Schneider PJ. Gift MG. Lee YP. Rothermich EA. Sill BE. Cost of medication-related problems at a university hospital. American Journal of Health-System Pharmacy 1995; 52(21):2415-8. 55.Sellers JA: Too many medication errors, not enough pharmacist. American journal of health-system pharmacy 2000; 57:337. 56.The National Coordinating Council for Medication Error Reporting and Prevention- About Medication Error. Available http://www.nccmerp.org/aboutMedErrors.htm. 57.Thomas EJ, Studdert DM, Newhouse JP, et al. Costs of Medical Injuries in Utah and Colorado. Inquiry. 36:255-64,1999. 58.Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: Preliminary retrospective record review. BMJ. 322:517-519, 2001. 59.Wilson RM, Runciman WB, Gibberd RW, et al. The Quality in Australian Health Care Study. Medical Journal of Australia 163:458-71, 1995. 60.World Health Organization: International drug monitoring: the role of the hospital. Technical Report Series No. 424. Geneva, World Health Organization, 1966. 61.石崇良(2003),「92年病人安全現況調查問卷結果」.Available http://www.tjcha.org.tw 62.亞東紀念醫院藥劑科,降低調劑錯誤率-QCC活動報告,2002。 63.林恆慶、陳楚杰、許銘恭:病人安全相關議題之探討。醫院 2003;36:69-77。 64.林慧玲、朱蓁蓁、高純琇、何蘊芳、游文瑛、黃甄彥、蘇錦玲、陳春雄:避免用藥的風險。台灣醫學 2002;6:228-42. 65.林慧玲、高雅慧、吳如琇、游文瑛、陳文慧、陳瓊雪:在台灣建立一個較安全的用藥制度。台灣醫學 2002;6:924-37. 66.財團法人醫院評鑑暨醫療品質策進會Available http://www.tjcha.org.tw/ 67.財團法人藥害救濟基金會。Available http://www.tdrf.org.tw/ 68.張必正(2003),醫師對於病人安全相關議題的認知、看法與因應行為之研究-以北部醫院醫師為例,國立台灣大學醫療機構管理研究所碩士論文。 69.張美智,周美惠,林明芳。以病人為中心用藥安全照護之規劃,醫院藥學 2003;20:115-122。 70.莊美華,林俊龍,王昱豐,曹汶龍,梁育彰。醫療機構用藥錯誤之探討。慈濟醫學雜誌2003;15(4):247-258。 71.陳昭姿主任,用藥安全之品質提升-以和信醫院為例,臺灣醫學會九十六屆總會專題討論-提升醫療安全之系統性作為(92/11/7).Available http://www.tjcha.org.tw 72.陳政興(2001),台灣北部醫學中心藥師工作壓力與工作滿意度之相關研究,國立東華大學企業管理學系研究所碩士論文。 73.曾美容(2003),醫院藥師壓力源與壓力反應的探討,雲林科技大學工業工程與管理研究所碩士論文。 74.優良藥品調劑作業規範(GDP)。藥事法施行細則。 75.羅文帥、何蘊芳、林麗貞、林慧玲:腫瘤化學治療藥品電腦開方失誤之探討;台灣醫學 2001;5:277-89. | |
dc.identifier.uri | http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/39163 | - |
dc.description.abstract | 本研究之目的為調查目前台灣的藥師調劑錯誤種類,進而探討造成調劑錯誤的危險因子,並依據研究結果對各醫院藥劑部門提出降低調劑錯誤的策略建議。在調劑錯誤的類型上,本研究主要採用ASHP(1993)提出的有關藥師調劑錯誤的類型,調查對象為地區教學醫院以上的藥師其常見調劑錯誤的種類。本研究採橫斷式問卷查,並與國內分布於各地區的59家醫院藥劑部門合作。在2個月的調查期間,共蒐集了811份有效問卷。本研究重要成果如下:
填答的藥師中女性佔73.5%;年齡則集中在20-39歲;工作職務大多為一般藥師;71.6%擁有大學以上學歷;工作單位以門診藥局居多,其次為住院藥局者;填答藥師有53.3%每月參加繼續教育的時數為1-4小時;每月查詢藥學資訊為1-5次者最多;有五成填答藥師的藥劑部門是依字母排列來擺放藥品,依藥理分類擺放藥品者佔35.2%。在填答藥師的自述中,發生調劑錯誤類型的頻率最高的為「數量錯誤」,發生頻率第二的錯誤為「藥名錯誤」,發生頻率排名第三的錯誤為「劑量錯誤」,排名第四為「因為藥品外觀相似而拿錯」。 藥師調劑錯誤的發生,會受到性別、年齡、婚姻狀況、工作總年資、工作職務、工作單位、工作班別、每月參加繼續教育時數、每月查詢藥學資訊頻率、每週實際工作幾個小時、門診處方量、是否有自動包藥機、藥品擺放規則、是否設有藥物錯誤通報專責單位、對於主動通報者的處理及醫院評鑑等級別的影響。 本研究根據以上結果提出以下建議:(1)建議部門主管應該多留意工作年資較淺的藥師,並配合適當的在職訓練與知識分享制度,使門診與住院藥局的藥師,在忙碌的調劑工作中能夠得到最新的藥學資訊。(2)本研究建議以字母及藥品代碼排列藥品的醫院改為依藥理分類擺放。此外設置錯誤通報的專責單位,及定期檢討與教育有關調劑錯誤之案例,也可以減少調劑錯誤之發生。(3)未來的研究者針對此一主題,可以嘗試將樣本擴大至地區醫院及診所藥師。在問卷題目設計上,未來研究可以採用某些標準量表,以測量如工作壓力之變項。 | zh_TW |
dc.description.abstract | The Purpose of this study is to understand the dispensing error type of hospital pharmacist and to explore the relationship between dispensing error and risk factor, and to bring up some suggestions for hospital pharmacy department according to this study outcome. To understand dispensing error of a pharmacist, ASHP (1993) pharmacist error types were applied. This study was a cross-section questionnaire survey which included 59 hospitals. Within collection period of two months, 811 valid questionnaires were obtained. Major results of this study were listed below:
Most of the respondents were female (73.5%) between the ages of 20 and 39, and are full time pharmacists; 71.6% are have a college degree or higher, work in place pharmacies catering to outpatients as well as inpatients. Most of those responding participate in extra education 1-4 hours on average a month and look up pharmaceutical information 1-5 times on average a month. 50% of pharmacy department the drugs were placed in alphabetical order while 35.2% were sorted according to the class of the drug. The most frequent types of errors in dispensing these drugs which I found is as follows: first, “the wrong quantity given”, second, “the wrong drug was given”, third “the wrong dose was given”, fourth “a look alike or similar drug was given”。 Respondents’ dispensing error is related to: gender, age, marital status, work seniority, work function, work unit, work class, average hour of education, average frequency of looking up pharmaceutical information, work time, prescription of outpatient service, automedication machine, the rule of placing the drug, establish the unit of reporting error, deal with initiative reporter, and hospital level. According to the above study, it would suggest: (1) the heads of pharmacy keep a closer tab on the younger less experienced pharmacists and be actively training these younger pharmacists to further their performance. (2) The way the drugs are sorted be changed from placing them alphabetically to placing them according to their pharmacology class. (3) Future researchers can add the standard questionnaire, and can consider expanding the object of study to local hospital and clinic pharmacist. | en |
dc.description.provenance | Made available in DSpace on 2021-06-13T17:05:33Z (GMT). No. of bitstreams: 1 ntu-94-P91843010-1.pdf: 1095351 bytes, checksum: 465b204a8fe12076598729daa4627448 (MD5) Previous issue date: 2005 | en |
dc.description.tableofcontents | 誌謝 ii
中文摘要 iii Abstract iv 目錄 v 第一章 緒論 1 第一節 研究背景與動機 1 第二節 研究目的 2 第二章 文獻探討 3 第一節 名詞定義 3 第二節 醫療錯誤的定義(medical error) 8 第三節 用藥錯誤(medication error)的定義 10 第四節 調劑錯誤的定義 16 第五節 造成調劑錯誤的危險因子 17 第六節 用藥錯誤通報及教育系統 19 第七節 用藥錯誤之預防 22 第八節 調劑錯誤的預防 24 第九節 綜合論述 27 第三章 研究材料及方法 28 第一節 研究架構 28 第二節 研究假說 29 第三節 研究變項與操作型定義 30 第四節 研究對象與選樣 36 第五節 研究工具 37 第六節 資料處理與統計分析 38 第四章 研究結果 39 第一節 問卷回收及填答情形 39 第二節 描述性統計分析 41 第三節 雙變項分析 55 第四節 多變項迴歸分析 63 第五節 深入訪談內容分析 67 第五章 討論 77 第一節 資料品質 77 第二節 描述性結果討論 79 第三節 研究假說驗證與討論 80 第四節 深度訪談結果討論 82 第五節 研究限制 84 第六章 結論與建議 85 第一節 結論 85 第二節 建議 86 參考文獻 87 附錄一 專家效度名單 93 附錄二 問卷 94 | |
dc.language.iso | zh-TW | |
dc.title | 藥師調劑錯誤之研究 | zh_TW |
dc.title | A Study of the Pharmacist's dispensing errors | en |
dc.type | Thesis | |
dc.date.schoolyear | 93-1 | |
dc.description.degree | 碩士 | |
dc.contributor.oralexamcommittee | 謝右文,楊銘欽 | |
dc.subject.keyword | 藥師,調劑錯誤, | zh_TW |
dc.subject.keyword | pharmacist,dispensing error, | en |
dc.relation.page | 98 | |
dc.rights.note | 有償授權 | |
dc.date.accepted | 2005-01-28 | |
dc.contributor.author-college | 公共衛生學院 | zh_TW |
dc.contributor.author-dept | 醫療機構管理研究所 | zh_TW |
顯示於系所單位: | 健康政策與管理研究所 |
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