應用績效形成因素分類法分析醫療院所用藥疏失之案例

Using A Taxonomy of Performance Shaping Factors to Analyze Cases of Medication Errors in Hospitals

宋俊億(Jyun-Yi Sung)

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(2014年)

https://doi.org/10.6840/cycu201400382

摘要

病人安全在現今社會裡是越來越受重視，人皆會生病，藥物對於病人就顯得重要，而相對來說藥物的正確使用及完整性就更為重要，那麼要如何有效的預防從事醫療相關人員使用藥物的失誤即是目前想要所達到的。本研究目的為依據以往用藥疏失的案例中造成失誤因素之探討，進而防止未來類似錯誤再度的發生，讓病人能安心的使用藥物，提高醫療品質降低醫療糾紛。研究流程可分為三個部分；第一部分依照宏觀人因工程的概念和使用績效形成因素法(PSF)，分類用藥疏失案例且紀錄疏失發生因素，再將用藥疏失發生的醫院類別及地區彙整。第二部分為將績效形成因素分類法(PSF)中，所記錄之疏失詳細特性發生的頻率做量化統計。第三部分為使用統計分析與柏拉圖分析，找出過往易發生用藥疏失的因素為何。研究結果顯示主要疏失的因素在於個人因素與工作因素上，而在更工作因素的詳細項目「標準化程度」與「格式或類型」因素分別出現13次與6次，第三高為個人因素的詳細項目「操作者判斷」出現5次。用藥是繁雜且步驟很多的流程，從醫師開立處方到病人服用藥物在這之間有許多的作業流程都是很容易因人為失誤而造成用藥疏失，因此人為失誤是需要盡全力去避免發生的，在用藥的過程中需要謹慎且要層層把關，且用藥的每個階段需透過不斷的精進與改善易出錯的流程，因此才能讓病人更安心的使用藥物，減少用藥疏失及醫療上的糾紛。

關鍵字

病人安全、用藥疏失、PSF

並列摘要

Patient safety is more attention in recent year, human would get sick, so medicine have seemed important for patient, furthermore the medicine perfection and completeness relatively would be most important, and then how could we prevent medication errors when health care worker operating what we want to research. This study was going to discussion how was made error from cases of medication error, as a result we will prevent each error which won’t happen again in future, it would let patient feel safety when they are taking medicine, and decrease caused medical conflicts and increase medical quality. My research process have three part. first, according to concept of Marcoergonomics and taxonomy of Performance Shaping Factors(PSF), in order to sort cases of medication errors and write down factor how to occur. Then we found the hospital what is the hospital level and where is the area of Taiwan. Second by PSF method, we could take down and count frequency the detail items of medication error . Third analyzed by statistics and Pareto diagram , to finding out which factor of medication error is easier to occur. According to result the primary error factors are human and task. There are three detail items of task and human, one is "level of detail" which is thirteen times ,another is "format or type" which is six times, the other is "operator diagnosis" which is five times. medication procedure is a complicate and many steps in it. In medication procedure, it was easier to make medication errors by human error, so it must to avoid any chance of error happened as possible as we can. Medication procedure must check precisely, and it would prove and be well in every medication procedure. Therefore, the patients could feel safety when using the medicine and decrease the dispensing error or medical dispute.

並列關鍵字

Patient safety ； medication error ； PSF

參考文獻

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[ 1 ] 行政院衛生署(2012) 年台灣病人安全通報系統年度報表；頁9.