以藥事工作為例，探討醫院藥局的人為失誤模式

調劑安全在台灣已經是風行已久的熱門話題。根據研究指出，有超過百分之七十的傷亡事故都是跟人為失誤有關，這也說明了，如何控制人為失誤已經成為世界性的難題。本研究的目的是要以地毯式的失誤分析方式，找出配藥失誤的潛在發生源。配合失誤分析方法，進行事前及事後的失誤評估。研究方式主要分成三個大項，第一部分為問卷分析，目的在了解人員對失誤的主觀概念，第二為失誤分析，目的在將失誤進行定性及定量，第三為作業現場實地看察，目的在評估藥事工作失誤模式。本研究目標站為南台灣某醫院，參與此研究的藥師共有46位。本研究分析其醫院內的失誤自發性通報系統，其中共有27,488,084筆處方資料，總共發生了32,966筆失誤，失誤率為0.12%；對藥局進行失誤模式分析，結果發現在此藥事工作站共有62個潛在的失誤來源，這個結果有助於往後對藥事工作的失誤模式建立以避免失誤發生，另外也可依此改進自發性通報系統。

關鍵字

人為失誤；配藥失誤；失誤模式；自發性通報系統

並列摘要

The Pharmaceutical Safety is a time-honored topic in Taiwan. Some studies have indicated that there were over 70％ of accident casualties related to Human Error. Because of its dimension, controlling the human error has become a global problem. The aim of this study is to investigate the pharmaceutical processes and to locate the human error factors by error analysis methods fore and aft. The methods of this study contain three parts. Part one is using questionnaire to survey the error self-knowledge, Part two is using error analysis to define errors in the quantity and quality. Part three is investigating the work activity to evaluate the pharmaceutical error. The study’s targeted pharmacy was in south Taiwan. There were 46 pharmacists enrolled in this research. This research analyzed its error self-reporting system and the data base was 27,488,084.The result shows that the error rate is 0.12%, and after the error model analysis, there are 62 human error factors found in the pharmaceutical processes. This result in pharmacy help to establish the error model to prevent these errors from happening again and to improve the error self-reporting system.