病人安全是一門越來越受重視的課題，用藥安全與降低用藥疏失是其中的重點，而 ”調劑疏失”是其主要原因。本研究目的是探討新竹市某區域教學醫院藥劑部藥師調劑疏失的原因，並針對已發生的調劑疏失作檢討。經由加強各項防禦機制、教育訓練與改善作業流程，期望能防止調劑疏失再度發生，達到零疏失之用藥安全為目標。本研究以回溯性的研究方法，收集自100年7月1日至101年6月30日新竹市某區域教學醫院藥劑部門、急診藥局處方1,636,540筆，住院藥局1,280,361筆處方。先以根本原因分析法 (RCA) 及醫療失效模式與效應分析法 (HFMEA) 分析出藥師調劑錯誤原因及類型，再以柏拉圖分析法的原則選出80/20需改善的標的。結果顯示門、急診藥局100年7月至12月調劑錯誤率為 0.0416%，經過各種品管方法介入改善，於101年01月至6月錯誤率降至0.0393%，全年調劑總錯誤率下降5.5%。住院藥局100年7月至12月調劑錯誤率為 0.0259%，於101年01月至6月錯誤率降至0.0241%，全年調劑總錯誤率下降6.9%。 以柏拉圖分析法分析門、急診藥師調劑疏失型態佔最高者為「品名相似」佔21%；住院藥師調劑疏失型態佔最高者則為「數量錯誤」佔29%。本研究結果加強了醫院全體藥師的參與感及改善調劑作業流程與工作環境，降低藥師作業時的調劑疏失，達病人用藥安全之目標。 The issue of patient safety is increasingly important and the key points of it are medication error and medication safety. However, one of the risks of medication safety is “dispensing error.” The purpose of this study was to explore causes of dispensing errors at a regional teaching hospital in Hsin-Chu. Through creating a fool-proofing design of hospital information system and improving pharmacists’ education and dispensing process to prevent the recurrence of dispensing errors to achieve the goal of medication safety.This study was a retrospective study. Research data were collected from prescriptions of inpatient and outpatient/emergency pharmacy from July 1, 2011 to June 30, 2012. The total numbers of prescriptions were 1,280,361 in inpatient pharmacy and 1,636,540 in outpatient/emergency pharmacy. Root cause analysis (RCA) and Healthcare Failure Mode and Effect Analysis (HFMEA) were firstly used to analyze the types of dispensing errors. Pareto analysis was next used to find the objects which should be improved. Through various quality control interventions, the average rate of dispensing errors decreased from 0.0416% (from July to December 2011) to 0.0393% (from January to June 2012), an improvement of 5.5%.Pareto analysis was also applied to find out the main cause of dispensing errors occurred in inpatient, outpatient and emergency pharmacy. The major cause of dispensing errors in outpatient and emergency pharmacy was “look-alike and sound-alike medicines” (occupied 21%) and it in inpatient pharmacy was “counting errors” (occupied 29%). Through this study, dispensing process and working environment were both improved in limited space and time. It also established “sense of crisis” for pharmacists when they practiced. Overall, the study was not only in line with the goal of patient safety but also provided a reference to other health care professionals.
