醫療院所藥師調劑門診處方之人為可靠度提升

Human reliability reinforcement of distributed prescription to out-patient clinic by pharmacists in hospital

褚軒麟(Hsuan-Lin Chu)

指導教授 ： 呂志維

中原大學/電機資訊學院/工業與系統工程研究所/碩士(2013年)

https://doi.org/10.6840/cycu201300698

摘要

病人安全為一直以來是所有人所關心的焦點，人皆會生病，藥物對病患就顯得相當重要，而藥物的正確性和完整性相對來說就更為重要了，如何有效提升門診配藥的人為可靠度就是現階段的重點，才能讓病人能夠更安心服用藥物。本研究目的為找出門診藥事流程中造成相關人為失誤的可能之因素探討，進而加以改善並防止類似錯誤再度發生，降低醫療糾紛，並降低人為失誤率，提升藥事人員人為可靠度。研究流程可分成三個部分；第一部分為階層式任務分析法(HTA)建立藥事流程並經由現場觀察及標準作業程序架構出完整任務的HTA。第二部分為使用系統化人為失誤減少與預測方法(SHERPA)進行失誤分析同時根據結果設計問卷並發放填寫，並找出關鍵的失誤模式。第三部分為人為失誤評估及降低方法(HEART)估算出每個動作的失誤率。研究結果顯示主要的失誤型態為行動失誤(Action Error)，其次為檢查失誤(Checking Error);人為失誤率方面，最高的人為失誤率為0.385882(判讀處方首頁)，次高的人為失誤率為0.169412(異常與醫師溝通)，第三高的人為失誤率為0.163765(醫師看診)。藥事流程為一種程序複雜且步驟繁多的流程，其目的為減少任何可能的人為失誤，必須盡全力避免失誤的發生，調劑的過程需要層層把關，但在流程上可能還是有稍嫌不足的部分，需透過不斷的改善與精進，才能讓病患更安心的使用藥物，減少調劑疏失與醫療糾紛。

關鍵字

人為可靠度 ； 人為失誤

並列摘要

Patient safety is always the aim which everyone were concerned,human would get sick, so medicine have seemed important for the patient, furthermore the medicine perfection and completeness would be most important for the patient, and then how could we improve the human reliability of distributed prescription to out-patient clinic is what we want to research. This study was going to find out the process of the distributed prescription which was made an error by human for discussion, as a result we will improve or control each error which won’t happen again, it would let people feel more safety and comfortable when they are taking medicine, and thus diminish caused medical conflicts. The research process have three parts:1)to use Hierarchical Task Analysis (HTA) to build up the standard procedure by observed the workplace in hospital of pharmacists,2)to use Systematic Human Error Reduction and Prediction Approach (SHERPA) to analyze error type and design the questionnaire for distribute at the same time, 3)to use Human Error Assessment and Reduction Technique (HEART) to calculate each movement failure probability and find out which is the most important thing we have to improve. We also give some advice for the hospital.Accroding to the result,the most frequency of the error is Action Error,the second of the error is Checking Error.In the aspect of human error probability,the hightest is 0.386(Reading the prescription information),the next is 0.170(communicate with the doctor when prescription had a problem),the third is 0.164(doctor diagnosis).Dispensing procedure is a complicate and many steps in it,and its aim is going to decrease any probability of human error, it must do a great effort to stop any chance of error happend.Dispensing procedure must check precisely,but some part of procedure is still not insufficiently,it must improve and revise countinuously, the patients could feel safety when using the medicine and decrease the dispensing error or medical dispute.

並列關鍵字

human error ； patient safty

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