運用品質改善手法降低住院藥局調劑跡近錯誤率

Quality Improvement Strategies to Decrease Dispensing Near Misses

以「病人安全為中心」的醫療照護是目前醫療管理主流，而提升用藥安全一直是病人安全目標推行的重要方向。本專案透過與院內資管組合作，運用品質改善手法和效果強、中、弱評估準則表，來評估並決定改善對策。目標為降低住院藥局調劑跡近錯誤率。結果顯示經由品質改善手法後，住院藥局調劑跡近錯誤率由原本的0.099%降至0.032%（P=0.027），具有明顯的改善。在持續追蹤六個月之後，調劑跡近錯誤率平均為0.04%。將結果作進一步分析發現，畢業後一般醫學訓練（post graduate year,PGY）藥師運用該品質改善手法，調劑跡近錯誤率的改善上較其他藥師低（31.6% Vs. 100%），顯示可能有不同的盲點，可考慮未來根據新進的PGY 藥師再用以品質改善手法去降低錯誤。本研究藉由品質改善手法，改善住院藥局調劑錯誤率，其所採用手法可提供同業參考，以降低相關錯誤，提升病人安全。

Patient safety is the mainstream of current healthcare management. Improving medication safety is a key factor in promoting patient safety. This project, which cooperated with information management department, used quality improvement techniques and strong/medium/weak assessment criteria to assess and build in improvement strategies. The goal was to decrease inpatient dispensing near miss rate. The results showed that the dispensing near miss rate was significantly decreased from 0.099% to 0.032% (P=0.027) after performing quality improvement techniques. The average dispensing near miss rate was 0.04% after six months followed up. By further analyzing the results, it revealed that pharmacists in post graduate year program had lower improvement on dispensing near miss rate than other pharmacists (31.6% vs. 100%) when used the same quality improvement techniques. It demonstrated that different groups of pharmacists may have different blind sides on dispensing. In the future, it could take into consideration to use the quality improvement techniques only for pharmacists in post graduate year program to further decreasing dispensing near miss rate. This project used quality improvement techniques to improve dispensing near miss rate. These strategies could provide other hospitals to decrease related near miss rate in order to improve patient safety.