- 學位論文
整合導入自動化藥櫃與實施單一劑量給藥模式之措施介入於藥物異常之成效探討
Integrating the introduction of automated medicine cabinets and the implementation of a single-dose administration mode to intervene in the effectiveness of drug abnormalities
摘要
本研究是利用根本原因分析導入自動化藥櫃是否能減少藥物異常事件，並分析其異常事件並提出改善及方法，進而減少藥物異常的發生率。 此次調查研究選取自2016年1月1日至2020年12月31日期間的藥物異常統計表之給藥錯誤事件，採用ECRS品管手法及根本原因分析導入自動化藥櫃前、中、後時期藥物異常錯誤事件，利用時序表了解事發當時內容，再利用失效樹分析確認根本原因並執行執行改善計畫及手法。結果發現在剛開始導入自動化藥櫃，因軟體與硬體上的不相容才導致異常事件發生，其次導入中時發現因自動化藥櫃未能有良好機制防止庫存量不足，且藥師也未能及時至單位補足藥物量，易導致藥櫃中藥物庫存不夠，最後在導入後分析發現，系統趨雖向於穩定，反而在人為失常事件上逐漸增加。 自動化藥櫃雖能減少藥物等待時間，提升藥物即時性，使護理人員方便取得藥品，但在取藥過程中，需自行取用藥物，在這過程中亦可能發生給藥異常，雖然設備可以優化給藥流程，但是有存在了許多潛在風險。
並列摘要
This study uses the root cause to analyze whether the introduction of automated medicine cabinets can reduce drug abnormal events, and analyzes the abnormal events and proposes improvements and methods to reduce the incidence of drug abnormalities. This investigation and research selected the medication error events in the statistical table of drug abnormalities from January 1, 2016 to December 31, 2020. The ECRS quality control method and root cause analysis were used to introduce the pre-, middle, and post-periods of the automated medicine cabinet For drug abnormal error events, use the time sequence to understand the content at the time of the incident, and then use the failure tree analysis to confirm the root cause and implement the improvement plan and method. It turns out that at the beginning of the introduction of the automated medicine cabinet, abnormal events occurred due to the incompatibility between the software and the hardware. Then, during the introduction, it was discovered that the automated medicine cabinet did not have a good mechanism to prevent insufficient inventory, and the pharmacist failed Replenishing the amount of medicine in the unit in time may easily lead to insufficient medicine inventory in the medicine cabinet. Finally, after the introduction, the analysis found that although the system tends to be stable, it is gradually increasing in man-made abnormal events. Although the automated medicine cabinet can reduce the waiting time of medicines, improve the immediacy of medicines, and make it easier for nursing staff to obtain medicines, but during the process of taking medicines, they need to take the medicines by themselves, and abnormal administration may also occur during this process, although the equipment can be optimized The drug delivery process, but there are many potential risks.