根據美國一份醫療疏失調查報告（To Err is Human）指出，美國每年因醫療疏失而引發的死亡人數高達44,000~98,000人左右，而造成不當用藥的用藥疏失為影響醫療疏失的關鍵因素之一。國內於2008年至2013年的病人安全目標與執行策略之首要目標為提升用藥安全；因此可見病人之用藥安全至今仍是醫藥界最關心的重要議題。故本研究之主要目的即探討新竹縣某地區教學醫院之醫師、藥師及護理人員對用藥疏失影響因素認知，以期降低醫院之醫療疏失。本研究以新竹縣某地區教學醫院為研究範圍，依據Gennaro 對用藥疏失之定義及彙整醫院過去一年用藥疏失發生之因素，歸類其因素類型，然後再以此為問卷設計之基礎，設計出醫師、藥師及護理人員對用藥疏失因素之瞭解認知問卷，再對醫院之醫師、藥師及護理人員進行問卷調查。研究結果發現藥師受訪者認為用藥疏失之主要因素為「藥名相似」、「外觀相似」及「位置相近」；醫師受訪者認為用藥疏失之主要因素為「病患肝腎功能不佳卻未降低量」、「交互作用造成劑量過高或過低」及「藥物交互作用導致不良反應」；護理人員受訪者認為用藥疏失之主要因素為「給錯藥品」、「給錯病患」及「注射劑有配伍禁忌沒有注意」。關鍵詞：醫療疏失、用藥疏失、用藥安全 According to a U.S. investigation report on medical errors (To Err is Human), there are up to 44,000~98,000 deaths reported every year due to medical errors. Medication errors that result in inappropriate dosing are also one of the key factors that contribute to medical errors. Therefore, from 2008 to 2013, the patient safety objective and the primary objective of strategy implementation in Taiwan are to enhance medication safety. Hence, it is apparent that medication safety among patients is still the most concerned issue of the medical community. The purpose of this study was to investigate the cognition of physicians, pharmacists and nursing staff in a district teaching hospital in HsinChu County towards factors contributing to medication errors, in order to lower the incidence of medical errors in the hospital. This study investigated a district teaching hospital in HsinChu County. Factors contributing to medication errors reported in the hospital during the past year were summarized based on the definition of medication errors defined by Gennaro. All factors were categorized and used as the basis for designing a questionnaire that explores the awareness of physicians, pharmacists and nursing staff towards factors contributing to medication errors. Physicians, pharmacists and nursing staff in the investigated hospital were targets for the questionnaire.According to the study result, the major factors that contribute to medication errors were perceived among the interviewed pharmacists as “similar drug names”, “similar appearance” and “close to position”. The major factors that contribute to medication errors were perceived among the interviewed physicians as “failure to reduce the dosage for patients with impaired hepatic and renal function”, “interaction effect that results in overdose or subtherapeutic dose” and “drug-drug interaction that results in adverse reaction”. The major factors that contribute to medication errors were perceived among the interviewed nursing staff as “wrong medication”, “wrong patient” and “failure to notice incompatibilities of injections”.
