摘要
目的：醫療錯誤所涵蓋的範圍很廣，因病患接受最多的治療方式為藥物治療，所以用藥疏失最值得探討。有鑑於台灣目前各醫療機構及專業人員對於用藥疏失的認知普遍不足，相關研究報告也尚未正式發表過，本研究以某區域教學院為例探討用藥疏失發生情形，提供其它醫療機構參考，達到預防或減少疏失發生的目的。材料與方法：本分析研究針對某區域教學醫院91年度所有院內用藥疏失案件加以統計分析。結果：91年度該機構用藥疏失件數為1,742件，佔總處方數的0.24%。主要疏常別以「處方開立錯誤」 最多(42%)，依序為「不符合健保給付規定」 (33%)、「輸入錯誤」 (24%)及「調劑錯誤」 (1%)。結論：用藥疏失的預防應著重於疏失發生原因的檢討與分析，落實通報系統功能是達成此目的的輔助工具之一。
並列摘要
Objective: Medical errors manifest themselves as different types; however, because drug therapy is the most common medical treatment received by patients, medication errors are the important error which needs to be discussed. In Taiwan, medication error reporting systems are not well developed yet. In addition, most health professionals are unaware of the potential causes of medication errors. The goal of this study was to share experiences with all health care institutions in Taiwan based on a teaching hospital’s medication error evaluation results. Materials and Methods: This study was conducted at a 1200-bed regional teaching hospital. All medication errors in 2002 were collected and analyzed. Results: In total 1,742 medication errors were documented, and the medication estimated error occurrence rate was 0.24%. The major types of errors were as follows: prescribing errors (42%), violating NIH (National Insur-ance of Health) drug reimbursement guideline errors (33%), prescription entry errors (24%), and dispensing errors (1%), respectively. Conclusions: Coclusions: Recognition of the problem is an important first step in developing strategies to minimize the occurrence of these errors. Reporting medication errors is an absolute necessity in order to gauge our progress and direct our efforts.