- 學位論文
某醫學中心問題處方通報系統之重建與住院問題處方之分析
Renovation of Prescribing Error Reporting System and Analysis of Inpatient Prescribing Errors in a Medical Center
摘要
研究背景： 開方失誤為用藥疏失的主要原因，而這一類的疏失卻是最常可以避免的。臺大醫院於2007年初住院醫療資訊系統轉型，影響了當時藥劑部院內網路住院問題處方通報系統的功能，藥師通報的住院問題處方數也因此降低。 研究目的： 建立一個新的住院問題處方通報系統並整合在臺大醫院醫療資訊系統中，以改善住院藥師問題處方通報的作業環境。利用新系統分析住院醫療服務之開方失誤，由政策面、系統面提出降低開方疏失的建議。 研究方法： 本研究包含三大部分：問卷調查、住院問題處方通報系統之建置及住院問題處方的分析。第一部分是藉由臺大醫院問題處方通報作業現況調查問卷，調查各住院調劑單位問題處方通報的作業現況、影響藥師通報問題處方的因素以及問題處方通報數下降的原因。第二部份是與藥劑部及資訊室合作，在臺大醫院醫療資訊系統內建置新的問題處方通報系統。最後藉由分析新系統上線半年後的住院問題處方數以及藥師利用新系統通報住院問題處方所需的時間來評估新系統的成效，並將舊系統、過渡系統、新系統的問題處方依照不同問題原因別、開方科部別、住院調劑單位別、藥品別、醫師接受率以及新系統各開方科部及各住院調劑單位的問題處方通報率進行敘述性統計及多元迴歸分析。 研究結果： 本研究發放問卷74份，回收70份，回收率94.6%，排除未使用問題處方通報系統的11份問卷後將59份問卷納入分析。由問卷調查發現藥師在過渡系統通報一件問題處方平均花費9.6分鐘。有57.6%的藥師表示願意及非常願意利用過渡系統通報問題處方，只有22%的藥師表示對過渡系統滿意及非常滿意。另外有28.8%藥師表示只通報被醫師接受的問題處方，有39.0%藥師會因為醫師不接受藥師建議，而降低通報意願。由迴歸分析發現，藥師對通報系統的滿意度會受到「新增功能是否方便」以及「通報問題處方是否可以幫助病人」所影響。通報意願則會受「認為通報意願會受電腦操作的熟悉度影響」、「認為通報意願會受選項的敘述清楚性影響」以及「認為通報問題處方可以加強自己的臨床技能」影響。 新建立的問題處方通報系統除了提供藥師新增、暫存、列印、修改、刪除，送組長等基本功能外，還增加許多進階功能（如：連結病人診斷及過敏史、依照時間、藥局、病歷號、建立者、學名、商品名、病房、分類是否為教案、狀態等交集搜尋功能、統計報表），讓通報紀錄除了為藥事服務紀錄外，還有臨床教育訓練的附加價值。新系統上線後，每月問題處方數增加為過渡系統的2.5倍；藥師使用新系統通報一件新問題處方平均需要3.1分鐘，較過渡系統減少6.5分鐘；藥師送交組長到組長核定的時間平均為2.2天。分析舊系統三年間82426件問題處方、過渡系統一年間6381件問題處方以及新系統半年間7915件問題處方可發現，舊系統每月平均問題處方數最多（2289.6件）；新系統次之（1319.2件）；過渡系統最少（531.8件）。若單看建議原因為藥師建議修改處方則新系統最多（1006.7件；76.3%）；舊系統次之（682.2件；29.8%）；過渡系統最少（394.3件；74.2%）。 舊系統的問題原因大部分為鍵入問題的「未在電腦取消應停藥醫囑」，此問題原因占舊系統所有問題處方的68.5%，過渡系統及新系統則主要為藥師建議修改處方，各占74.2%和76.3%。新系統平均問題處方通報率為0.9%，急診醫學部的問題處方通報率最高（1.4%）；其次為外科部（1.3%）；小兒部與創傷外科部均為1.1%；內科部通報率為1%。在調劑單位方面，無菌調配靜脈營養調劑組的問題處方通報率最高（4.4%）；其次為化療調劑組（1.9%）；總院住院調劑組與公館住院調劑組均為1.2%；急診調劑組的問題處方通報率最低（0.3%）。 新系統排名第一的問題藥品為抗生素類製劑，平均每月有423.3件問題處方，占全部的32.1%；其次為胃腸道用藥以及新陳代謝及營養製劑，各占全部的11.9%和11.8%。在醫師接受率方面舊系統的總接受率最高（94.8%），其次為新系統（92.5%），陽春過渡系統最低（89.9%）。不論在哪一個系統，鍵入問題的醫師接受率均居所有問題原因之冠，都高於98%。新系統除了鍵入問題略低於舊系統外，其他問題原因的接受率均明顯高於舊系統及陽春過渡系統。 結論： 新的問題處方通報系統上線後至今快一年，由於設計人性化並增加許多進階功能，成功改善藥師問題處方通報的作業環境，每月問題處方數增加為過渡系統的2.5倍，通報所需的時間比過渡系統減少6.5分鐘，提升藥師通報意願及問題處方資料完整度。藉由新的問題處方通報系統，能迅速偵測到住院病人最常出現處方問題的藥品及原因，進而由政策面、系統面研擬防止開方失誤的方法。 新系統的創新之處在於除了基本的通報功能外，藥師還可以透過新的問題處方通報系統及資料庫來共享通報的問題處方個案，更可以透過藥品查詢、病房查詢、教案查詢的功能，將通報的問題處方有效地整合應用，讓問題處方通報系統成為資訊教育平台，強化藥師的在職訓練，有效地降低開方疏失，保障病人安全。
並列摘要
Background: Prescribing errors are the most common type of medication errors and are often preventable. Implementation of a new computerized physician order entry (CPOE) system in National Taiwan University Hospital impaired part of the function of the old prescribing error reporting system. The number of prescribing errors reported by pharmacists also declined. Objective: The aim of this study was to renovate an efficient and effective prescribing error reporting system in a medical center and to analyze the errors reported by this system. Method: This study included a questionnaire survey, implementation of a new prescribing error reporting system and prescribing error analysis. Firstly, a questionnaire survey was conducted to evaluate the current status of prescribing errors reporting, factors that affect prescribing errors reporting and the reasons why reported prescribing errors decreased. Secondly, through collaboration between department of pharmacy and information systems office, a new prescribing reporting system was implemented in the new CPOE system. Finally, the effectiveness of the new system was evaluated through the analysis of the reported prescribing errors, according to the error types, prescribing departments, pharmacy divisions, medication categories, physicians’ acceptance rates, and prescribing report rates. Result: A total of 70 questionnaires were returned for a response rate of 94.6%. After excluding 11 pharmacists who did not use the old reporting system before, 59 questionnaires were included in this study. It took pharmacists 9.6 minutes to report one prescribing error by using the transitional system. Although there were 57.6% of pharmacists willing to report prescribing errors, only 22% of pharmacists were satisfied with the transitional system. Around 28.8% of pharmacists only reported the interventions that were accepted by physicians, and 39.0% pharmacists’ willingness to report prescribing errors declined when physician turned down their suggestions. Multiple logistic regressions showed that pharmacist’s satisfaction toward reporting system was influenced by “the convenience of data entry” and “the helpfulness to the patients”. In addition, the willingness to report errors depended on “the familiarity with the computer system”, “the clearness of the definition” and “potentialities of the reports to improve clinical skill”. There was also some advancement in the new system including database queries, teaching function and the statistical report. Averagely, the new system took pharmacists 3.1 minutes to report one prescribing error, which was 6.5 minutes faster than the transitional system. It took an average of 2.2 days for a chief pharmacist to verify a documented error. Prescribing errors identified in the old system, transitional system and new system were 2289.6, 531.8, and 1319.2 per month respectively. Excluding entry errors, those orders changed due to “pharmacists’ cognitive service” in the old system, transitional system and new system were 682.2 (29.8%), 394.3 (74.2%), and 1006.7 (76.3%) per month respectively. The most common error in the old system was “failure to discontinue the order on computer” (68.5%), while the most common error in the transitional and new system was “pharmacists’ cognitive service” (74.2% and 76.3% respectively). The prescribing error rate reported by the new system was 0.9%. The highest error rate was found in the emergency medicine department (1.4%), followed by the surgery department (1.1%). Of all the inpatient pharmacies, the prescribing error rate of parenteral nutrition pharmacy, oncology pharmacy, inpatient pharmacy in main region, inpatient pharmacy in kung-kuan region and emergency room pharmacy was 4.4%, 1.9%, 1.2%, 1.2%, 0.3%, respectively. The most common medication class among the prescribing errors was antimicrobial agents (423.3 prescriptions/month; 32.1%), followed by gastrointestinal agents (157.5 prescriptions/month; 11.9%), and metabolic and nutrients agents (155.3 prescriptions/month; 11.8%). The physicians’ acceptance rates for pharmacist’s intervention in the old system, transitional system and new system were 94.8%, 92.5% and 89.9%, respectively. The physicians’ acceptance rates of “entry error” were highest (>98%) in all the three systems. The physicians’ acceptance rates of all types of errors in new system were higher than old system and transitional system except for “entry error”. Conclusion: The newly implemented prescribing error reporting system successfully replaced the transitional system because of its user-friendly design and novel functions. It facilitated pharmacists’ willingness to report and thus provided information for strategy planning in prescribing errors prevention. The novelty of the new system is that pharmacists can share the prescribing error database. Data can be integrated as a teaching material through database queries. Therefore, prescribing errors can be reduced and patient care quality can be achieved through education symposiums for medical and pharmacy professionals.