腫瘤化學治療藥品電腦開方失誤之探討

Prescribing Errors of Chemotherapeutic Agents Through a Computerized Prescribing System

化學治療藥品在腫瘤治療中佔有不可或缺的角色，由於這些藥品大多具有細胞毒性（cytotoxicity），若使用不慎或給錯藥品，會帶來嚴重的後果。本研究乃針對臺大醫院1999年8月至2000年5月間所使用的腫瘤化學治療藥品，就醫師之電腦開方失誤，作敘述性統計，希望能藉此找出常見而可預防的錯誤，並作進一步的檢討，以供日後改進之用。於十個月的研究期間總計56705筆的腫瘤化學治療藥品電腦處方中，藥師偵測到的電腦開方失誤共397筆（失誤率0.70%），其中絕大多數為日期錯誤，佔59.45%；其次為重複開方，佔13.35%。在397筆處方中，高危險性的錯誤佔了26.71%（失誤率0.19%），包括藥品錯誤（9.32%）、劑量錯誤（11.34%）、給藥頻次錯誤（3.53%）及開錯病人（2.52%）。這些錯誤如未發現，結果都極可慮。由本研究之發現有數點可做改進之處：一、電腦開方系統及處方作業流程的改善；二、專業人員的教育與訓練；三、醫療相關專業人員彼此充分的溝通。希望透過本文的討論及分析，使醫護人員更重視腫瘤化學治療藥品開方之正確性，也更能重視藥師在醫療團隊中的角色，達到提供病患最完整的醫療服務之目的。

Chemotherapeutic agents play an essential role in treating neoplastic diseases. Due to their cytotoxic cffects, any error occurred during prescribing, dispensing, or administration processes may result in serious consequences. Prescribing errors of chemotherapeutic agents in a computerized prescribing system detected by pharmacists between August 1999 and May 2000 at the National Taiwan University Hospital were analyzed. We aimed to delineate errors commonly seen in order to caution healthcare providers against such preventable inappropriateness. Three hundred ninety-seven prescribing errors were detected from a total of 56705 electronic prescriptions during the 10-month period. The prescribing error rate was 0.70%, yet 26.21% of which may be deemed as high risk errors. These high risk prescribing errors included incorrect drugs (9.32%), inaccurate dosages (11.34%), erroneous frequencies (3.53%), and wrong patients (2.52%). If these errors were left unnoticed, serious morbidity or even mortality may ensue. Certain preventive measures may be implemented to reduce such errors, including the improvement of electronic prescribing system, arrangement of educational programs for healthcare professionals, and fortification of better communication among healthcare team members. Our study indicates that pharmacists are certainly one of the key healthcare members in providing sound services to patients. Through the in-depth analysis of prescribing errors from this study, we hope that all professionals can pay more attention to the safe use of chemotherapeutic agents during their routine practices.