住院病患給藥安全調查 -以某區域教學醫院為例

The Study of Inpatients Medication Safety - An Example of Regional Teaching Hospitals

黃瑞蘭(Jui-Lan Huang)

指導教授 ： 張泳源

高雄醫學大學/健康科學院/公共衛生學研究所碩士在職專班/碩士(2004年)

摘要

研究目的：
1999年美國醫學研究機構（Institute of Medicine），指出美國每年因可避免的醫療錯誤（preventable medical errors）造成約有九萬八千人的死亡，台灣在民國91年底相繼發生兩起重大之醫療錯誤，震驚了台灣社會，然而根據歐美等先進國家的經驗，醫療專業人員若對於醫療錯誤有正確瞭解，根據不同的發生原因及結果擬定改善對策，可大大的減少醫療錯誤的發生。本研究藉由某一區域教學醫院的經驗，探討給藥過程潛在性錯誤率及藥物安全之風險程度，是否因病患及醫護人員人口學特質而有影響，及實施住院病患給藥安全風險管理策略後，給藥過程潛在性錯誤率及藥物安全之風險程度是否有改善，另外調查區域醫院不同權屬別之住院病患給藥安全及風險管理策略應用之現況，以為醫療機構發展病患安全策略之參考。
材料與方法：
本研究參酌相關文獻後，編訂「住院病患給藥安全檢查表」作為研究調查工具，以結構性觀察研究法進行住院病患給藥安全調查，研究對象是樣本醫院之住院病患、主治醫師、護理人員、藥劑師、事務員等進行兩階段調查，所得資料整理後應用SPSS10.0版套裝軟體進行描述性統計、無母數分析、單因子變異數分析、對數迴歸分析、複迴歸分析法，並應用類實驗研究法進行單一組住院病患給藥安全風險管理前後之比較。
結果與討論：
經研究結果發現醫療人員在執行給藥過程之的任何一個點皆有可能發生潛在性錯誤，其發生率有61%與Brennan（1991）58%及 Wilson（1992）54%和Thomas(1999) 51.2%類似，而在護理人員部份發生率45%、藥劑師25%、事務員有16%，與Bates（1995）研究結果相似，針對潛在性失誤進行對數迴歸分析結果，住院病患每增加一種注射針劑潛在性失誤比率就增加55%， 65歲以上病患其潛在性失誤是65歲以下的1.7倍，與Brennan（1991）研究結果相似。
結論與建議：
不論研究結果如何，均顯示的一個事實，就是在醫療過程中，病患扮演的是一個無辜及脆弱的角色，因為在醫療環境中常會發生相當比率之醫療潛在性危機，而給藥過程潛在性錯誤發生率部份竟然高達61%，如何改善給藥安全系統提升病患安全，是各醫療機構責無旁貸之重要任務。綜合以上結果建議：
一、 建請衛生主管機關能訂定本土化之病患安全具體目標及建置病患安全通報文化。
二、 醫療機構管理者能提供完善之病患給藥設施，發展病患安全通報系統。
三、 對後續研究者建議，可加入醫師做病歷審查要項，能應用較長時間規劃風險管理策略及執行，擴大進行研究範圍，以利研究結果之外推性。

關鍵字

潛在性失誤 ； 病患安全 ； 藥物錯誤 ； 風險管理

並列摘要

Objective:
In 1999, American Institute of Medicine pointed out that the preventable medical errors in America caused the death rolls of 98000 each year. There were two vital medical errors successively happening in Taiwan in 2002 and made people astonished. However, according to experiences from the advanced Western countries, medical personnel can considerably minimize the occurrence of wrong medical treatments as long as they have correct understandings to medical errors and draw up strategies of improvement, based on different factors. The research, through experiences of a regional teaching hospital, is to discuss the rate of potential medical errors in process of medicine-administrating and risks of medicine safety. We investigated whether the patients and medical personnel affect the results. Moreover, we deliberated whether the situation of medical errors has been improved after carrying out the strategies of medicine-administrating management. Besides, we inquired inpatients of different competency in the regional hospital and researched into the safety of medicine-administrating along with current situation in applied risk management, referential for other medical institutions on these issues.

Material and Method:
After referring to relevant bibliographies, a “checklist of safe medicine-administrating for inpatients” was edited as the tool for this research to investigate safety of medicine usage by making structural observation. The research is targeted to inpatients, attending doctors, nursing staff, pharmacists and office clerks of the sample hospital; the investigation was divided into two phases. Since we came up with the results, we applied to Software of “SPSS10.0 edition” to do the “Descriptive Statistics”, “Nonparametric Statistics Analysis”, “One-Way ANOVA ”, “Logistic Regression Analysis”, “Multiple-Regression Analysis”. Furthermore, a single-group of inpatients was chosen to make comparison between before/after practice of risk management by way of quasi-experiments.

Consequence and Discussion:
The research has shown that the potential errors can probably happen in every process of administrating medicine. The probability is 61%, similar to results of Brennan, 58% (1991), Wilson, 54% (1992), and Thomas, 51.2% (1999). For the nursing staff, the probability is 45% whereas 25% in pharmacists and 16% in office clerks— the result is similar to Bates (1995). The potential errors applied by “Logistic-Regression Analysis” came up with the fact that the probability of errors increases 55% as long as the inpatients take one more injection. Those who are above 65 years old are exposed themselves to 1.7 times of potential errors than those who are under 65 years old. This consequence is similar to Brenann’s (1991).

Conclusion and Suggestions:
No matter what the consequences are, it is a fact that the patients play innocent and fragile roles in the process of medical treatments, for there is a very high ratio of potential medical errors in which the inaccuracy of medicine-administrating even reaches 61%. It is an unshirkable responsibility for every medical institution to better safety systems in medicine-administrating and guarantee the security of patients. To sum up, we suggest as the following:
1. The hygienic agencies should set up localized specific goals for patient safety and customs of safety notification.
2. The superintendents of medical institutions should provide complete facilities for medicine-administrating and develop systems of safety notification. For the follow-up researchers, we suggest that they ask the doctors to recheck case histories and medical records, planning longer time frame for executing risk managements and expanding ranges of researches, in order to extrapolate the consequences of the research.

並列關鍵字

Potential error ； Risk management ； Medication error ； Patient safety

參考文獻

一、 中文部份：

1 王靜儀（1999），「環境災害消費與比較性風險評估之研究」，台北大學都市計劃研究所碩士論文。

2 林宏榮（2003），病患安全風險因素之研究，國立成功大學館理學院高階管理碩士在職專班碩士論文。

3 林惠珍（1994），處方簽內容問題分析之實證研究，國立陽明醫學院醫務管理研究所碩士論文。

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