運用人因工程優化藥事作業流程之成效探討

Discussion on the Effect of Using Human Factors Engineering to Optimize the Operation Process of Pharmacy

因門診藥局調劑跡近疏失率高，從現況分析、收集數據並進行真因驗證，找出九項真因，提出八項改善對策：一、包藥機配藥；二、藥盒設置零散藥品放置區；三、藥袋加註最小包裝量；四、拆掉隔間；五、調整藥品擺放位置；六、個人化資訊警示；七、條碼覆核系統；八、優化藥品標籤。調劑跡近疏失率由0.17%降至0.09% (p=0.0006)，效果維持0.09%；數量錯誤導致調劑跡近疏失率由0.134%降至0.069% (p=0.00047)，效果維持0.067%；外型相似導致調劑跡近疏失率由0.014%降至0.006% (p=0.056)，效果維持0.008%；品名相似導致調劑跡近疏失率由0.0083%降至0.0020% (p=0.005)，效果維持0.0009%。因執行成效佳，近幾年將人因概念的改善模式如藥品位置擺設、調劑動線設計、智慧設備的購入推廣至急診與住院藥局，藉以降低藥師工作負荷，消除因疲勞而引起的人為失誤，建構一個友善工作職場環境。

Due to a high rate of dispensing errors in the outpatient pharmacy, we conducted an analysis of the current situation, collected data, and verified the root causes. We identified nine true causes and proposed eight improvement measures: 1.implementation of automated dispensing machines, 2.creation of designated areas for storing scattered medications in medicine boxes, 3.labeling medication bags with minimum packaging quantities, 4.removal of partitions, 5.adjustment of medication placement, 6.personalized information alerts, 7. implementation of barcode verification systems, and 8.optimization of medication labels. As a result of these improvements, the dispensing error rate decreased from 0.17% to 0.09% (p=0.0006), and the effect was sustained at 0.09%. The rate of errors caused by quantity mistakes decreased from 0.134% to 0.069% (p=0.00047), with a sustained effect of 0.068%. Errors caused by similar appearances decreased from 0.014% to 0.006% (p=0.056), with a sustained effect of 0.006%. Errors caused by similar drug names decreased from 0.0083% to 0.0020% (p=0.005), with a sustained effect of 0.0008%. Due to the successful implementation, in recent years we have extended the concept of human factors improvement, such as medication placement, dispensing workflow design, and the adoption of intelligent devices, to the emergency department and inpatient pharmacies. This has helped reduce the workload of pharmacists, eliminate human errors caused by fatigue, and create a friendly working environment.