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題 名 | 運用HFMEA改善值班時段調劑作業=Using Healthcare Failure Mode and Effect Analysis to Reduce Dispensing Errors by a Sole Pharmacist in the Hospital Pharmacy |
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作 者 | 莊謹如; 謝承穎; 蔡佩玲; 陳宜屏; 廖玲巧; | 書刊名 | 藥學雜誌 |
卷 期 | 34:3=136 2018.09[民107.09] |
頁 次 | 頁130-136 |
分類號 | 418.82 |
關鍵詞 | 調劑流程; 單人值班; HFMEA; Dispensing process; Sole pharmacist; Medication safety; |
語 文 | 中文(Chinese) |
中文摘要 | 本研究應用醫療照護失效模式與效應分析 (Healthcare failure mode and effects analysis, HFMEA) 手法,減少醫院藥師於單人值班時段發生調劑錯誤。根據本院通報 調劑異常事件統計,單一藥師值班時段發生調劑錯誤比率高達60%,其風險高於同時 段存在兩名或多名藥師值班。 我們依 HFMEA 步驟審視調劑程序,以流程圖描述調劑過程,並進行危害指數分 析,確定了38種失效模式和61種潛在失效原因。遵循決策樹分析選出需矯正流程,並 擬定改善策略,例如啟用24小時自動化包藥機系統、調整單人調劑覆核流程以及培養 正確調劑態度...等。改善行動實施後,危害指數由230降至199,整體調劑錯誤比率由 610.4 ppm 降至406.1 ppm。 本次 HFMEA 改善活動,其結果可供醫院藥師單人值班作業流程參考。我們建議: 藥物調配系統自動化及資訊化是減少調配錯誤率的重要工具,此外,應針對藥師單人 值班訂定新的確核程序,並將調配錯誤報告轉化為教材,建構藥師正確的調劑態度。 |
英文摘要 | In this study, Healthcare Failure Mode and Effects Analysis (HFMEA) is applied to reduce the incidence of dispensing errors during the dispensing process from a sole pharmacist in the hospital pharmacy. A sole pharmacist has higher risk of dispensing errors compared with two or more pharmacists present at one time. The most common factors affecting the error are to do with being busier than normal or interruptions (telephone interruption, query from member of staff, etc.). We used HFMEA to check the dispensing procedures, graphically describing the process, and conducting a hazard analysis. The results showed that it was a high risk dispensing process by a sole pharmacist. 38 failure modes and 61 potential failure causes are identified. Several strategies were determined for prevent the potential dispensing errors during the sole pharmacist dispensed in hospital pharmacy, such as the automated drug dispensing machines system, the establishment of the verification process and 4 ways to develop the right attitude towards dispensing prescriptions et al. In the pre- and post-strategic actions implementation periods, the hazard score were decreased from 230 to 199. The overall rates of dispensing errors were decreased from 610.4 ppm to 406.1 ppm. According to the above study, we would suggest: the automation and computerization of drug dispensing are important tools for reducing dispensing error rates. The dispensing error reports were transformed into teaching materials to educate the sole pharmacist. Moreover, pharmacists’ attitude should be developed and the new checking procedures practiced by a sole pharmacist should be established. |
本系統中英文摘要資訊取自各篇刊載內容。