藥師調劑錯誤之研究

A Study of the Pharmacist's dispensing errors

陳瑞瑩(Jui-Yin Chen)

指導教授 ： 陳端容

國立臺灣大學/公共衛生學院/醫療機構管理研究所/碩士(2005年)

https://doi.org/10.6342/NTU.2005.02623

摘要

本研究之目的為調查目前台灣的藥師調劑錯誤種類，進而探討造成調劑錯誤的危險因子，並依據研究結果對各醫院藥劑部門提出降低調劑錯誤的策略建議。在調劑錯誤的類型上，本研究主要採用ASHP(1993)提出的有關藥師調劑錯誤的類型，調查對象為地區教學醫院以上的藥師其常見調劑錯誤的種類。本研究採橫斷式問卷查，並與國內分布於各地區的59家醫院藥劑部門合作。在2個月的調查期間，共蒐集了811份有效問卷。本研究重要成果如下：
填答的藥師中女性佔73.5%；年齡則集中在20-39歲；工作職務大多為一般藥師；71.6%擁有大學以上學歷；工作單位以門診藥局居多，其次為住院藥局者；填答藥師有53.3%每月參加繼續教育的時數為1-4小時；每月查詢藥學資訊為1-5次者最多；有五成填答藥師的藥劑部門是依字母排列來擺放藥品，依藥理分類擺放藥品者佔35.2%。在填答藥師的自述中，發生調劑錯誤類型的頻率最高的為「數量錯誤」，發生頻率第二的錯誤為「藥名錯誤」，發生頻率排名第三的錯誤為「劑量錯誤」，排名第四為「因為藥品外觀相似而拿錯」。
藥師調劑錯誤的發生，會受到性別、年齡、婚姻狀況、工作總年資、工作職務、工作單位、工作班別、每月參加繼續教育時數、每月查詢藥學資訊頻率、每週實際工作幾個小時、門診處方量、是否有自動包藥機、藥品擺放規則、是否設有藥物錯誤通報專責單位、對於主動通報者的處理及醫院評鑑等級別的影響。
本研究根據以上結果提出以下建議：(1)建議部門主管應該多留意工作年資較淺的藥師，並配合適當的在職訓練與知識分享制度，使門診與住院藥局的藥師，在忙碌的調劑工作中能夠得到最新的藥學資訊。(2)本研究建議以字母及藥品代碼排列藥品的醫院改為依藥理分類擺放。此外設置錯誤通報的專責單位，及定期檢討與教育有關調劑錯誤之案例，也可以減少調劑錯誤之發生。(3)未來的研究者針對此一主題，可以嘗試將樣本擴大至地區醫院及診所藥師。在問卷題目設計上，未來研究可以採用某些標準量表，以測量如工作壓力之變項。

關鍵字

藥師 ； 調劑錯誤

並列摘要

The Purpose of this study is to understand the dispensing error type of hospital pharmacist and to explore the relationship between dispensing error and risk factor, and to bring up some suggestions for hospital pharmacy department according to this study outcome. To understand dispensing error of a pharmacist, ASHP (1993) pharmacist error types were applied. This study was a cross-section questionnaire survey which included 59 hospitals. Within collection period of two months, 811 valid questionnaires were obtained. Major results of this study were listed below:
Most of the respondents were female (73.5%) between the ages of 20 and 39, and are full time pharmacists; 71.6% are have a college degree or higher, work in place pharmacies catering to outpatients as well as inpatients. Most of those responding participate in extra education 1-4 hours on average a month and look up pharmaceutical information 1-5 times on average a month. 50% of pharmacy department the drugs were placed in alphabetical order while 35.2% were sorted according to the class of the drug. The most frequent types of errors in dispensing these drugs which I found is as follows: first, “the wrong quantity given”, second, “the wrong drug was given”, third “the wrong dose was given”, fourth “a look alike or similar drug was given”。
Respondents’ dispensing error is related to: gender, age, marital status, work seniority, work function, work unit, work class, average hour of education, average frequency of looking up pharmaceutical information, work time, prescription of outpatient service, automedication machine, the rule of placing the drug, establish the unit of reporting error, deal with initiative reporter, and hospital level.
According to the above study, it would suggest: (1) the heads of pharmacy keep a closer tab on the younger less experienced pharmacists and be actively training these younger pharmacists to further their performance. (2) The way the drugs are sorted be changed from placing them alphabetically to placing them according to their pharmacology class. (3) Future researchers can add the standard questionnaire, and can consider expanding the object of study to local hospital and clinic pharmacist.

並列關鍵字

pharmacist ； dispensing error

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