建置小兒用藥極量檢核提升用藥安全專案

Project to Establish an Extreme Dosage Audit for Enhancing Drug Safety in Pediatrics

目的：小兒族群的藥品劑量主要以mg/kg計算，然而目前病人端缺乏完整體重資訊、警示系統未區分小兒與成人、藥品檔缺乏小兒極量資料。方法：運用品管圈問題解決型找出三項真因：劑量檢核邏輯不適用於小兒族群、未強制輸入身高體重、藥品主檔缺乏小兒極量設定，進而擬定對策。結果：小兒劑量過高的異常件數，改善前為2件，目標降至0件，改善後為1件。再介入：主因劑量計算後有時會微調成整數可能略高極量，因此現行警示訊息皆為提示。與臨床科共識，增設極量的1.1倍設為阻擋，追蹤至2023年7月未再有異常件數。結論：本次專案改善後成效良好推廣至體系醫院，共同提升小兒用藥安全，然而藥品品項繁多，尚需持續進行資料建檔以提供更全面的把關。

 

Objective: Pediatric dosages are primarily mg/kg-based. However, currently, patient records lack complete weight information, the alert system does not differentiate between pediatric and adult patients, and the drug database lacks pediatric maximum dosage data. Methods: Using a quality control circle problem-solving approach, we identified three root causes: dose checking logic not applicable to the paediatric population, not mandatory input of height and weight, and lack of paediatric limit settings in the drug master file. Subsequently, we formulated countermeasures. Results: The number of overdosage exceptions in children was 2 before improvement, and the target was reduced to 0 and 1 after improvement. Re-intervention: The main reason for this is that dose calculations are sometimes rounded to slightly higher extremes, and therefore the current warning messages are all alerts. In consensus with clinical departments, a 1.1-fold limit was added as a blocking measure and tracked to July 2023 with no further abnormalities. Conclusion: The improved results of this project will be extended to hospitals in the system to enhance the safety of paediatric drug use. However, as there are many different types of drugs, there is still a need to continue to build up data to provide more comprehensive gatekeeping.