Title

醫療院所藥師調劑門診處方之人為可靠度提升

Translated Titles

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

Authors

褚軒麟

Key Words

人為可靠度 ; 人為失誤 ; human error ; patient safty

PublicationName

中原大學工業與系統工程研究所學位論文

Volume or Term/Year and Month of Publication

2013年

Academic Degree Category

碩士

Advisor

呂志維

Content Language

繁體中文

Chinese Abstract

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。

English Abstract

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.

Topic Category 電機資訊學院 > 工業與系統工程研究所
工程學 > 工程學總論
Reference
  1.  Ashcroft DM, Quinlan P, et al. (2005). "Prospective study of the incidence, natureand causes of dispensing errors in community pharmacies." Pharmacoepidemiol Drug Saf 14(5): 327-32.
    連結:
  2.  Annett J,(2004), Hierarchical task analysis. Handbook of CognitiveTask Design, 17-36
    連結:
  3.  Beso A, Franklin BD, et al. (2005). "The frequency and potential causes of dispensing errors in a hospital pharmacy." Pharm World Sci 27(3): 182-90.
    連結:
  4.  Chua SS, Wong IC, et al. (2003). "A feasibility study for recording of dispensingerrors and near misses' in four UK primary care pharmacies." Drug Saf 26(11):803-13.
    連結:
  5.  Embrey DE,(1986), SHERPA: a systematic human error reduction and prediction approach. Paper Presented at the International Topical Meeting on Advances in Human Factors in Nuclear Power Systems, Knoxville, Tennessee.
    連結:
  6.  Flynn EA, Barker KN, et al. (2003). "National observational study of prescription dispensing accuracy and safety in 50 pharmacies." J Am Pharm Assoc (Wash) 43(2):191-200.
    連結:
  7.  Lesar, Timothy S.; Briceland, Laurie, et al. (1990) Medication Prescribing Errorsin a Teaching Hospital. JAMA 263 (17):2329-2334.
    連結:
  8.  Leape LL, Berwick DM. (2005) Five years after ToErr Is Human: what have we learned? JAMA; 293:2384-90.
    連結:
  9.  Lasala KP, (1998), Human Performance Reliability: A Historical Perspective. IEEE Transactions on Reliability; 47 (3): 365-371.
    連結:
  10.  Peterson GM, Wu MS, et al. (1999). "Pharmacist's attitudes towards dispensingerrors: their causes and prevention." J Clin Pharm Ther 24(1): 57-71.
    連結:
  11.  Rasmussen J, (1986), Information processing and human-machine 82 interaction: An approach to cognitive engineering, New York: North Holland.
    連結:
  12.  William JC, (1986), HEART: a proposed method for assessing and reducing human error. Proceeding 9th Advances in Reliability Technology Symposium, University of Bradford.
    連結:
  13. [ 1 ] 張一岑(1998)人因工程學,揚智文化事業股份有限公司。
    連結:
  14. [ 2 ] 廖仁傑(2003)To Error Is Human?-有關人為錯誤之探討,品質月刊;11 期:35-39。
    連結:
  15. [ 9 ] 莊美華、林俊龍、王昱豐、曹汶龍、梁育彰:醫療機構用藥疏失之探討。慈濟醫學2003;15:247-258
    連結:
  16. [ 11 ] 楊哲銘、邱文達、林靖瑛、許英娟;建構醫療機構病人安全監測指標之前驅實證研究。台灣衛誌 2009;28(1):78-84
    連結:
  17. [ 13 ] 吳玉琴、張慧真、戴淑華、陳俊名、周辰熹(2010);利用更改藥名標示來降低調劑錯誤率之成效評估。(台灣醫學Formosan J Med 2011;15:129-35)
    連結:
  18. [ 14 ] 張慧珍(2006);醫院藥局藥品調劑疏失之探討-以南部某醫學中心為例。成功大學高階管理碩士在職專班碩士論文。
    連結:
  19. [ 15 ] 葉世傑(2012);醫院院內放射診斷技術師拍攝胸腔X光影像流程人為可靠度提升。高雄醫學大學職業安全與衛生研究所碩士論文。
    連結:
  20. [ 17 ] 行政院衛生署:台灣病人通報系統2011年年報,財團法人醫院評鑑暨醫療品質策進會。
    連結:
  21. 英文文獻:
  22.  American Society of Safety Engineers, 1988, Dictionary of terms Used in The Safety Profession, 3rd, Des Plaines, IL: ASSE.
  23.  Alireza Noroozia, Faisal Khana, Scott MacKinnona, Paul Amyotte b, Travis Deaconb,(2012)Determination of human error probabilities in maintenance procedures of a pump.Published by Elsevier B.V. on behalf of The Institution of Chemical Engineers.
  24.  Bird, F.E., &Germain, G.L. (1996).Practical Loss Control Leadership.Norway: DNV.
  25.  Rasmussen J, (1982), The definition of human error and a taxonomy for technical system design, In Rasmussen J, Duncan K, and Leplat J(eds.), New technology and human errors, John Wiley and Sons, New York .
  26.  Reason JT, (1990), Human Error, Cambridge University Press, Cambridge, UK.
  27.  T. Deacon, P.R. Amyotte, F.I. Khan, S. MacKinnon (2012),a framework for human error analysis of offshore evacuations.Faculty of Engineering & Applied Science, Memorial University, St. John’s, NL, Canada.
  28.  Utah-Colordo Study, (2001). Quality of care:patient safety, Executive Board (109th) session.
  29. 中文文獻:
  30. [ 3 ] 林明芳(2002)藉由用藥疏失管理提升病人用藥安全,藥學期刊;97期:3-8。
  31. [ 4 ] 李念宗、李季黛、葉明欽、吳臺莉、李貫棠(2008),門診藥物疏失與處理流程之探討。
  32. [ 5 ] 李心潔、遲蘭慧、葉俊彤、陳新言、陳筱玫、高啟蘭、鄭繼鳳、吳曉芳、林龍鈺、林惜燕(2006),減少門診調劑錯誤率。
  33. [ 6 ] 譚延輝(2003),藥師與判斷性服務,九州圖書文物有限公司。
  34. [ 7 ] 高美智:「戴明循環」與「起司理論」,自由時報;92.1.30
  35. [ 8 ] 楊秀儀:台灣醫療糾紛之迷思與真相。博士論文,美國史丹福大學,1997
  36. [ 10 ] 鄭佩珊、徐士傑、莊謹如、廖彩馨、廖玲巧;調劑疏失、人人皆會犯錯 - 某區域教學醫院之調劑錯誤實例研究。藥學雜誌;98期:143-149
  37. [ 12 ] 林恆慶、陳楚杰、許銘恭:病人安全相關議題探討。醫院 2003;36:3。
  38. [ 16 ]許國敏、莊秀文、莊淑婷(2006):病人安全管理與風險管理實務導引,華杏出版股份有限公司。
Times Cited
  1. 宋俊億(2014)。應用績效形成因素分類法分析醫療院所用藥疏失之案例。中原大學工業與系統工程研究所學位論文。2014。1-51。
  2. 連彥滕(2015)。運用人因工程分析醫療院所病人安全案例 ─以提升用藥安全、落實感染管制及提升手術安全為例。中原大學工業與系統工程研究所學位論文。2015。1-64。