藥師判斷性服務系統建置及應用於潛在性用藥疏失管理之效益分析

System Development and Benefit Evaluation of Management of Potential Medication Error for Pharmacist Cognitive Service

徐俊生(Chun-Sheng Hsu)

指導教授 ： 蕭震緯

亞洲大學/資訊學院/生物資訊學系碩士在職專班/碩士(2009年)

摘要

用藥安全一直都是國內外醫藥界關心且致力改善的議題，對於不適當的藥品處方、藥局調劑錯誤或是護理人員給藥錯誤等一連串的疏失，結果可能不僅僅會造成無法預期的後果而危及病人安全的事件，對於整個醫療團隊及病人家屬更會造成嚴重的影響。本研究利用研究醫院藥事部門用藥疏失通報系統內的資料，經切步統計分析用藥疏失案件的類型後，嘗試建構一個Web-based架構的「藥師判斷性服務系統」，可以讓藥師在接受處方箋後(或分析藥歷檔之後)，若發現有藥物治療問題，針對問題進行介入活動，以解決問題之所有過程行為能夠完整詳實的留下記錄；此外，於執行一段時間後除了分析藥物治療問題的類別、進行介入的方式及介入後之結果外，在整體方面亦分析系統對用藥安全提供的實際成效。
藉由「藥師判斷性服務系統」的建置，我們可以確切得知在給藥程序的整個流程中有多少跡近錯誤 (near miss) 發生；而在藥師的專業把關及努力之下又有多少錯誤能夠及時避免。若疏失原因屬於人為因素，則從人員的教育訓練著手；若為系統性、組織架構性的問題，在於發現易造成錯誤的作業環境，並針對個別問題一一改善。如在藥局端，例如：藥名相似、外觀相似的藥品分開存放，高危險的藥品設立高警訊藥品專區存放，經常性調劑錯誤的藥名採用Tall-Leg方式提醒等等；在醫令端則可加強電腦的輔助，將有清楚明確定義的部份在資訊系統中設限或出現提示畫面。
藉由記錄、分析錯誤原因及檢討改善的手段，提醒醫師在處方開立上或藥師在處方調配上可能發生的盲點。同時，所有醫療人員也能藉由瀏覽系統內的案例而達到共同學習、累積經驗、提昇身為醫療工作專業人員所需具備的核心專業能力的目的，對於病患的用藥能一起把關，提供零疏失的醫療服務。

關鍵字

病人安全 ； 用藥疏失 ； 調劑疏失 ； 用藥安全 ； 藥師判斷性服務

並列摘要

Medication safety has been the domestic and foreign medicine circles concerned about and committed to improving. Such as a series of inappropriate drugs for the prescription, pharmacy dispensing or nursing staff administration blunders , the result may possibly not only lead to unpredictable consequences and endanger patient safety incidents, for the entire medical team and the patient's family may result in seriously affected. In this study, the pharmaceutical research hospital medication error reporting system sector data, after preliminary statistical analysis of the type of medication error cases, the attempt to build a Web-based architecture, "Pharmacist cognitive service system", allowing pharmacists in accepted the prescription (or analysis of medicine record files), if discovered that has treatment question, in view of issues involved in activities to solve the problem of the behavior of all the process can leave a detailed record of integrity; In addition, after a period of time in implementation, in addition to analysis of the types of treatment questions, Approach to intervention, and the results of intervention, also in the overall analysis of the system to provide the actual effectiveness.
Because of “Pharmacist Cognitive Service System” establishing, we may exactly know how many near miss to occur in the entire flow of medicine administration process , and how many mistakes can avoid promptly diligently in pharmacist's professional service. If the mistake reason belongs to the human factor, the education and training to the staff to proceed; if for systemic or organizational structure of the problem, Lies in the discovery risk factors of the operating environment, and improve the response to individual problems one by one. In pharmacy, for example: The name is similar, the outward appearance similar drugs separate depositing, the high alert drugs set up a special area depositing, the frequent dispensing error drugs to use Tall-Leg way to remind etc.; In HIS, may strengthen computer's auxiliary, will have the clear part of the definition of the limits of information systems or the screen prompts.
By records, analysis of error causes and the self-criticism improvement's method to remind physicians prescribing in the prescription or pharmacists in dispensing that mistake may occur. At the same time, all medical officers can also browse through the system's case to achieve study, the cumulation experience, to enhance the core specialized competence of health care professionals, for patients with medication to check and provide a perfect medical service.

並列關鍵字

patient safety ； medication error ； medication safety ； pharmacist cognitive service

參考文獻

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