以約略集合理論推演同成分與非同成分藥品調劑疏失之原因
Abstract
調劑疏失的發生又可分為「人」與「系統」兩部份。本研究將方向定為探討如何調整「作業系統」以改善「人」調劑疏失的機率。企圖瞭解藥品外觀、藥品名稱、貯存位置、藥品劑型、劑量與藥理分類等對藥品調劑疏失的影響。本研究以北部某教學醫院105~106年門診調劑疏失通報紀錄時正本分析架構之可行性。擬分別應用約略集合理論及關聯理論探討一些調劑疏失風險因子對同成分藥品及非同成分藥品調劑疏失兩因素間之決策屬性與關聯情形。最後再比較兩種研究方法的結果。依據實證研究之結果，藥品外觀包裝型態(例如:文字形狀、排裝大小、包裝顏色) 、藥品名稱(成分名、商品名)相似度、藥品調劑貯存位置、藥品的藥理分類、藥品多重劑量、劑型等,均為藥品調劑疏失的因素。依據本實證研究之結果，建議藥品可附加外觀特徵；高低含量者加以「高」「低」警示；改變藥名大小寫;附加藥理提示；調整鄰近位置;中文名標示提前；易混淆警語;加強同仁對於同類藥品的辨識；加入劑型提示；數字大小有所不同;品名相似者外觀印至藥袋上作提示等方案,以達利用系統輔助降低藥品調劑錯誤發生率,來完成提高病患用藥的保障。
Because the occurrence of the dispensing errors can be divided into two parts: "person" and "system",this study explores how to adjust the 「operating system」to improve the probability of 「human 」disorder. Therefore, this study try to understand the influence of appearance of drugs, drug name, storage location, pharmaceutical dosage form, dose and pharmacological classification to dispensing errors. This study is based on the data of dispensing errors notification system in someone north teaching hospital outpatient department between years of 2016 ~ 2017, and we use rough set theory to definite the rules of some risk factors to dispensing errors that those two drugs are the same or not ingredients. Then, this study use association theory to understand the relationship strength between dispensing errors' factors and dispensing errors itself. In addition, finally, we can compare the results in Rough Set throry with the results in Association theory. According to this empirical study, the appearance of the drug packaging (size, shape, color), drug name (generic name, trade name) similarity, drug storage location, drug pharmacological classification, drug dosage, dosage form, etc., are all risk factors of dispensing errors. It is recommened that by this study, medicine bag should be used to add appearance features; high and low dose content medicine to be "high" and "low" warning; change the drug name case; add pharmacological tips; adjust the adjacent location of other. Chinese name can be marked in advance. The warning of easy to confuse is more obvious. Adding the dosage form of tips and bigger letter means larger number of medicine. The warning of similar product appearance is printed on the package for tips and other programs. Besides enforcing coworkers' identification of the same type of drug is very important. By above mention; we can expect to reduce the incidence of drug dispensing errors and to improve the protection of patients with drugs.
Because the occurrence of the dispensing errors can be divided into two parts: "person" and "system",this study explores how to adjust the 「operating system」to improve the probability of 「human 」disorder. Therefore, this study try to understand the influence of appearance of drugs, drug name, storage location, pharmaceutical dosage form, dose and pharmacological classification to dispensing errors. This study is based on the data of dispensing errors notification system in someone north teaching hospital outpatient department between years of 2016 ~ 2017, and we use rough set theory to definite the rules of some risk factors to dispensing errors that those two drugs are the same or not ingredients. Then, this study use association theory to understand the relationship strength between dispensing errors' factors and dispensing errors itself. In addition, finally, we can compare the results in Rough Set throry with the results in Association theory. According to this empirical study, the appearance of the drug packaging (size, shape, color), drug name (generic name, trade name) similarity, drug storage location, drug pharmacological classification, drug dosage, dosage form, etc., are all risk factors of dispensing errors. It is recommened that by this study, medicine bag should be used to add appearance features; high and low dose content medicine to be "high" and "low" warning; change the drug name case; add pharmacological tips; adjust the adjacent location of other. Chinese name can be marked in advance. The warning of easy to confuse is more obvious. Adding the dosage form of tips and bigger letter means larger number of medicine. The warning of similar product appearance is printed on the package for tips and other programs. Besides enforcing coworkers' identification of the same type of drug is very important. By above mention; we can expect to reduce the incidence of drug dispensing errors and to improve the protection of patients with drugs.
Description
Keywords
調劑疏失, 用藥安全, 約略集合理論, 關聯理論, Dispensing error, drug safety, rough set theory, association theory