住院自動配方機配藥錯誤之原因分析

Analysis of the medication errors in automatic dispensing system

美國健康體系藥師學會（American Society of Health-System Pharmacists, ASHP）在自動配藥設備之安全性建議指引指出，將藥物正確地放入自動配方系統為一重要課題，為防範給藥錯誤疏失的發生且提高用藥安全，必須針對自動配方系統作業流程，全面且仔細評估可能發生的問題，深入剖析作業相關潛在問題，作為預先防範用藥疏失的策略。我們利用根本原因分析（RCA）方法及瑞士乳酪理論模式找出本院配方機配藥錯誤原因，並擬定對策加以改善，以期建構更安全的自動配方作業系統，以提升病人用藥安全。

How to correctly deliver medications to the automatic dispensing system is animportant issue, according to The American Society of Hospital Pharmacists (ASHP) guidelines on the safe use of automatic dispensing devicesIn order to prevent the medication errors, we must carefully assess the potentialproblems for the automated medication storage and distribution devices in themedication-use process. We use Root cause analysis (RCA) method and Swisscheese model to find out the root causes for medication errors in automaticdispensing system at our pharmacy, and propose strategies to improve patientmedication safety.