降低自備藥給藥異常發生率之方案

A Program to Reduce the Incidence of Adverse Medication Events with Self-prepared Medicine

目的:自備藥給藥異常是常見的問題,透過品管圈來解決這個棘手的問題,期望達成有效改善。

方法:分析 2018 年 6 月的統計數據,發現自備藥給藥異常發生率為 63.3%,故成立 品管圈。檢視其原因,以柏拉圖驗證後發現「藥師未即時評估」、「自備藥物標示不清」為問題要因,據此擬定對策措施,並利用 Plan-Do-Check-Action 手法進行對策檢討和效果確認。

結果:對策實施後,自備藥給藥異常發生率由改善前 63.3%,下降至 28.6%(目標值為 37.1%),目標達成率為 132.4%、進步率為 54.8%,顯示運用品管圈的 改善方法效果良好。

結論:利用品管圈手法,改善自備藥審查流程,除降低給藥異常發生率、提升藥師滿意度外,推動小組在品管手法運用、活動信心方面,亦有顯著進步。

 

Objectives: The incidence of adverse medication events with self-prepared medicines is a common problem in routine clinical practice. This study investigates the effi- cacy of a quality control circle (QCC) to decrease the incidence.

Methods: Data for June 2018 were analyzed, and the results revealed a delay rate of 63.3%. Thus, a QCC was established to decrease the rate .Through Pareto analysis, the QCC identified that “no immediate assessment by pharmacists” and “unclear labeling of self-prepared medicines” were the root causes of damage. Accordingly, the QCC formulated solutions, which were subsequently verified by the Plan–Do–Check–Action.

Results: After the implementation of the countermeasures, the incidence decreased from 63.3% to 28.6% (the target value was 37.1% ). The goal achievement was 132.4%, and progress was 54.8%. The findings showed the use of QCC works well.

Conclusion: This program can help our hospital to improve self-prepared medical reviews. It reduces the incidence of adverse medication events with self- prepared medicines and enhances pharmacists’ satisfaction. Therefore, this program is a useful strategy to improve medical management.