頁籤選單縮合
題名 | 建立藥品使用前取用防錯檢核機制=Establish an Error Avoidance Preview Procedure to Prevent Medication Errors |
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作者姓名(中文) | 林冠伶; 吳大圩; 劉惠琪; 黃碧蕙; | 書刊名 | 藥學雜誌 |
卷期 | 32:4=129 2016.12[民105.12] |
頁次 | 頁115-120 |
分類號 | 419.39 |
關鍵詞 | 調劑錯誤; 跡近錯失; 給藥錯誤; Dispensing error; Near miss; Medication error; |
語文 | 中文(Chinese) |
中文摘要 | 評鑑及衛生局督導考核都提及,藥品調劑錯誤跡近疏失 (near miss) 或給藥異常都 應有檢討改善措施,但普遍醫院都是在錯誤發生之後才開始檢討。某醫療機構翻轉檢 討機制,建立藥品使用前取用防錯檢核機制,經實施5年後顯著減少因同成分不同劑 型、同成分不同劑量、藥名相似、外觀相似之調劑錯誤 near miss。分析該機構103年 發生之212件調劑錯誤 near miss,經取用防錯檢核的藥品3個月內發生 near miss 件數 (31件),為未經檢核或檢核超過3個月者 (181件) 的六分之一。普遍機構內會同時存在 多種 Look-Alike, Sound-Alike (LASA) 藥品,若因軟硬體設備、藥師人力、候藥時間 等因素無法運用條碼系統防止錯誤發生,則實施該流程可得到妥善管理,防止開立錯 誤及給藥疏失。 |
英文摘要 | According to the regulations and requirements of certain accreditations, hospitals should review the causes of medication errors and make the corresponding avoidance strategies. However, when these reviews are being implemented, medication errors have already occurred. We examined the mistake review procedure to integrate an error avoidance preview to our daily practice and check up if (1) medication names similarities, (2) medication appearances similarities, (3) medications with different strengths or (4) medication with different dosage forms are existed prior to the medications use. After 5 years' practices, the prevalence of near miss dispensing error regarding to 4 items described above, is significantly decreased from 0.0086% (1st year, 2009) to 0.0055% (2nd year, 2010) (p < 0.001) and averaged 0.0047% (during 5 years (2009-2014)) (p < 0.001). Hospital could consider applying this error avoidance preview procedure to avoid Look-Alike, Sound-Alike (LASA) near miss dispensing errors if barcode system is hard to be supported during dispensing practice. |
本系統之摘要資訊系依該期刊論文摘要之資訊為主。