利用用藥安全自我評量調查結果進行藥事品質改善之相關研究

Studies on Pharmacy Quality Improvement Based on the Findings from Medication Safety Self-Assessment Survey

莊美華(Mei-Hua Chuang)

指導教授 ： 詹道明

高雄醫學大學/藥學院/藥學研究所/博士(2011年)

https://doi.org/10.6832/KMU.2011.00010

摘要

現代醫學已經越來越複雜，即使是最好的處置也可能為病人帶來非預期的結果，甚至造成傷害。”首要是不造成傷害”為每位醫療專業人員必須遵循的優先原則。病人安全所涵蓋的範圍很廣，因病患接受最多的治療方式為藥物治療，所以用藥安全最值得探討。本論文研究目的主要分為兩個部分，第一部份是利用2004年版本的ISMP Medication Safety Self-Assessment® for hospitals作為醫院用藥安全執行狀況的調查工具，調查結果可作為日後改善重點的參考。第二部分則是依據ISMP Medication Safety Self-Assessment® for hospitals評量結果，實施具體的改善策略，提供藥事部門建置一套更安全的藥物使用系統應用於臨床業務的執行。
在第一部份的研究依據台灣醫療環境的模式，將2004年版本之ISMP Medication Safety Self-Assessment® for hospitals加以編修及翻譯（中文）成一份調查手冊；主要實施對象為南台灣包括雲林、嘉義、台南等三個縣市的所有醫院（共63家）。總共有53家醫院完成自我評量，結果顯示平均得分較高的構面為：環境因素、工作流程及人員配置型態；但在病人資訊、藥物資訊這兩個構面得分最差。其他構面，如：藥物醫囑或其他藥物資訊的溝通；藥物標準化、儲存及配送；藥物標示、包裝及命名；病人教育；品質管控及風險管理；人員能力及教育訓練；及藥物儀器的採購、使用及監測等也是得分偏低的項目。從南台灣醫院用藥安全自我評估的調查結果可知，目前各醫療院所對於ISMP所建議之用藥安全應實施內容執行情況普遍不彰，這代表仍有非常多用藥安全相關的作業急需改善。改善的優先順序應該考量現行執行情況比較差的構面開始。
根據第一部份的研究結果，規劃出第二部分研究主軸。主要針對病人教育、藥物資訊、及藥物標示、包裝及命名這三個構面提出改善策略。第一個相關研究探討病人教育的問題，主要是針對老人及低教育程度的病人，藉由藥物使用圖示的設計（共12組，分成四大類，每類有三個不同圖示），確認這類病人與醫療人員對於圖示的瞭解程度及喜好有何不同。結果顯示病人對於這12組圖示的喜好與專業人員有顯著差異。其中，病人無法瞭解圖示代表什麼意思的比率比醫療人員高。對於藥物投與頻率及藥物是否於飯前、中、後給予的圖示，病人與專業人員在瞭解程度上有顯著差異。病人對於圖示的喜好及瞭解程度與年紀有關。為了確實達到良好的病人教育，以藥物使用說明圖示加以輔助是有幫助的。但應注意在設計圖示時，應確實諮詢各種不同類別的病人，尤其是老人或教育程度較低病人，以利達到應有的效果。
第二個相關研究則是探討藥物標示、包裝及命名的改善。針對忙碌的藥劑部門，有鑑於匆促的調劑時間、不足的藥物資訊及數目眾多的藥品，調劑錯誤的發生是很難避免的，則利用新設計的藥品儲位標示，即於標示上提供更多、更適當的藥物資訊，且另外標示有其他重要注意事項提醒（如：多劑型、多種含量規格、外型/外包裝/藥名相似），同時搭配調劑防錯措施，藉由藥師滿意度及調劑錯誤率的分析加以評估成效。研究結果顯示，藥師對於新式儲位的格式設計及內容標示的滿意度相較於舊式儲位標示整體上均有提升且達統計上的差異。此外，調劑錯誤率也明顯降低。調劑作業是容易發生疏失的過程，一個能提供較充分的藥品儲位標示設計且搭配有調劑防錯措施，可有有效提升藥師滿意度及降低調劑錯誤率。
第三個研究主要討論藥物資訊的品質改善，利用藥袋上印有藥物圖檔增加藥物辨識方便性，並以問卷調查藥師的滿意度程度。病人在實施藥袋印有藥物圖檔目的的宣導活動後，利用問卷調查檢視其前後滿意度的差異。結果顯示，所有的藥師對於藥袋上印有藥物圖檔覺得有幫助或非常有幫助。每月平均調劑錯誤率也有顯著降低。約82％的病人表示藥袋上印有藥物圖檔對於用藥安全有幫助。病人整體滿意度在實施宣導活動後有明顯提升。
建立一個更安全的醫療系統是很重要的，所有醫療專業人員必須更加努力以利重拾大眾對於醫療系統的信賴。為了達這個使命，以最真實的態度執行用藥安全自我檢視與評估以利確認機構內藥物使用過程及內部結構是否完整與適當是必須的。藥事品質改善是需要不斷持續進行的過程以利減少藥事部門的用藥疏失。所有藥事人員皆需要採取行動於如何能更掌握品質保證的原則及疏失的降低；藉由不同部門經驗的學習、提供工具及策略以利確認、通報及分析疏失，及鼓勵病人主動參與疏失的預防。

關鍵字

藥事品質改善 ； 用藥安全自我評量

並列摘要

Contemporary medicine has become more and more complex. The most optimum treatment can cause patients unexpected outcomes, even adverse consequences. “First, do no harm” is one of the principal precepts of medical ethics that should be followed by all medical professionals. The scope of patient safety is very broad. The use of medication remains the most common intervention in health care. Therefore, the focus on reduction of medication errors and implementation of continuous quality improvement processes is the first priority in today’s healthcare agenda. The objectives of studies in this dissertation are to: (1) identify opportunities for enhancing safe medication practices by using the survey of ISMP Medication Safety Self-Assessment®; and (2) provide quality improvement strategies to establish a safer medication use system in pharmacy at our clinical settings.
In the first part of study, the 2004 edition of ISMP® Medication Safety Self-Assessment® for Hospitals was translated and modifiedbased on the current practice model in Taiwan. Surveys were distributed to all hospitals in three counties of southern Taiwan. Out of a total of 63 hospitals in southern Taiwan, 53 hospitals completed the survey. In these 53 participating hospitals, they scored highest in domains related to environmental factors, workflow and staffing patterns. The survey results demonstrated that enormous opportunities exist to improve medication safety, especially in domains related to patient information and drug information. In addition, improvements are needed in domains related to communication of drug orders and other drug information, drug standardization, storage and distribution, drug labeling, packaging and nomenclature, patient education, quality processes and risk management, staff competency and education,and medication device acquisition, use and monitoring.
Based on the findings from the first part of self-assessment survey study, three relatedstudies were proposedto improve the quality in domains ofpatient education, drug information, and drug labeling, packaging, and nomenclature. In the first study ofpatient education improvement, pictographsdepicting medication use instructions for low-literacy medical clinic ambulatory patients were developed. The survey used a third version of 3 sets of pictographs in 4 medication instruction categories for low-literacy patients and medical staff. The preference of pictographs was significantly different between patients and medical staff for each of the 12 sets of pictographs. Comprehension was significantly different between patients and medical staff for pictographs in the categories of medication administration time of day and medication administration associated with meals.Patients’ preferences for and comprehension of the medical instruction pictographs were age-related. For successful development of a comprehensible prescription drug label, a diverse sample of patients should be consulted to ensure that the pictographs depicting medication use instructions are useful to all individuals, including those with low literacy.
For improving the quality of drug labeling, packaging, and nomenclature,a study of implementation of a new drug storage label and error-reducing process on the accuracy of drug dispensingwasconducted. Because of limited time available for dispensing, the limited amount of drug information available and the large variety of drugs kept in the typical pharmacy, pharmacists may make errors. The new label included additional information relating to multiple dosage forms of the drug as well as cautionary labels alerting the dispenser to other drugs that may be similar in appearance. At the same time, pharmacists were requested to follow a new error-reducing dispensing process. This study showed that the implementation of the new storage label and the error-reducing process was effective in decreasing the overall drug-dispensing error rate and increasing the pharmacists’ degree of satisfaction with the storage label design compared to the previous label used.
In the third study, for the purpose of improvingdrug information, medication photographs printed on medicinebagsfor increasingmedication identification and satisfaction among pharmacists and patients at a medical ambulatory clinicwas studied. All of the pharmacists thought that printing the photograph and information about the medication was helpful or very helpful for making the medication safer to use. The monthly average medication dispensing error rate was significantly decreased. More than 80% patients considered a medication appearance photograph on the medicine bag as helpful for medication safety. The satisfaction with a medication appearance photograph among the public was increased. In addition, printing medication photographs on medicine bags can help the patients and pharmacists identify and use medications more safely.
In conclusion, in order to regain the public’s trust and truthfully achieve toward building a safer health care system, an honest assessment of medication safety is needed to identify processes and organizational structures that cause errors.Pharmacy quality improvementis a constant process that attempts to reduce medication errors in the pharmacy.Pharmacy staffs should take actions on how to better understand the principles of quality assurance and error reduction; share lessons learned from low-error systems outside of pharmacy; provide tools and strategies for identifying, reporting, and analyzing errors; and empower patients to do their part to prevent errors.

並列關鍵字

Pharmacy quality improvement ； Medication Safety Self-Assessment

參考文獻

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