A Drug Safety Risk Management and Assessment Mechanism for Community Pharmacy in Taiwan

台灣社區藥局用藥安全風險管理評估機制之建構

10.29977/JCIIE.200909.0003

張碩毅(She-I Chang)；吳思佩(Celeste See-Pui Ng)；史雅男(Ya-Nan Shih)；洪國堯(Guo-Yao Hung)

用藥疏失 ； 社區藥局 ； 紮根理論 ； medication error ； community pharmacy ； grounded theory

工業工程學刊

26卷5期（2009 / 09 / 01）

344 - 354

英文

藥局具有買賣業與專業服務業特性，與其他產業不同之處在於其風險性質，藥局產業最大風險來源爲「用藥疏失」。台灣在邁入高齡化社會以及醫藥分業政策日漸成熟後，社區藥局之用藥安全愈趨重要。本研究採用紮根理論進行文獻整理，歸納出影響社區藥局用藥安全之風險因子及風險管理評估雛型，同時以德爾菲方法進行此雛型之修正與確認，採用層級程序分析法來分析風險評估項目之權重，最後建構出一套完整、客觀且符合社區藥局作業流程之用藥安全風險評估量表。本研究之成果，將有助於社區藥局及相關醫療體系在日後擬訂更完善的風險管理策略。

Pharmacy is a specialized service industry, with unique inherent risks different from other industries. The biggest risk source of the pharmacy industry is ”Medication Error”. As our community enters into an aging society and the policy of separation of prescribing and dispensing gradually matures, the importance of drug safety of the community pharmacy increases. This study applies the grounded theory to find the critical risk factors of medication error from the literature review, adopts the Delphi method to revise these factors and uses the analytic hierarchy processing methodology to analyze each element in our proposed drug safety risk management and assessment mechanism. This study contributes to the community pharmacy by developing the drugs safety assessment model to help the pharmacy to have a better understanding of the risk factors associated with its day-to-day business operations and to provide references to pharmacists in setting up more complete risk management strategies in the future.

1. National Hospital website
2. Enterprise risk management-integrated framework
3. Department of Health website R.O.C.
4. NCC MERP (The National Coordination Council for Medication Error Reporting and Prevention)
5. American Society of Health-System Pharmacists(1993).ASHP guidelines on preventing medication errors in hospitals.American Journal Hospital Pharmacists,50,305-314.
6. Barker, K. N.,E. A. Flynn,G. A. Pepper,D. W. Bates,R. L. Mikeal(2002).Medication errors observed in 36 health care facilities.Archives of Internal Medicine,162,1897-1903.
7. Come with a strong intension of Chain pharmacy
8. Chuang, M. H.,C. L. Lin,Y. F. Wang,W. L. Tsao,Y. C. Liang(2003).Medication errors in health care institutions.Tzu Chi Medical Journal,15,247-258.
9. Chung, Y. C.,M. C. Lin(1995).Management of Modern Pharmacy.Taipei:Kingdom.
10. Cohen, M. R.(1999).Medication Errors: Causes, Prevention, Risk Management.DC:Jones and Barlett.
11. Dawson, K. P.,A. C. Penna,D. Drummond,C. Sharpe(1993).Prescription errors in a children's ward: audit and intervention.Australian Journal of Hospital Pharmacy,23,326-328.
12. Department of Health, R.O.C.(2003).National Health Policy Conference-final Report,Taipei:
13. Medication errors food and drug administration
14. Fortescue, E. B.,R. Kaushal,C. P. Landrigan,K. J. McKenna,M. D. Clapp,F. Federico,D. A. Goldmann,D. W. Bates(2003).Prioritizing strategies for preventing medication errors and adverse drug events in pediatric inpatients.Pediatrics,111,722-729.
15. Fowles, J.(1978).Handbook of Futures Research.Connecticut:Greenwood Press.
16. Fry, L. M.,A. N. Jones,G. T. Swan(1985).Prescription writing: incidence of errors and their effect on pharmacy workload.Australian Journal of Hospital Pharmacy,15,95-98.
17. Gowin, D. B.(1981).Educating Ithaca.NY:Cornell University Press.
18. Hepler, C. D.,L. M. Strand(1990).Opportunities and responsibilities in pharmaceutical care.Australian Journal of Hospital Pharmacy,47,533-543.
19. Medication errors in the emergency department drug topics health-system edition
20. Hsu, S. T.(2006).Market of pharmaceutical industry and future development in Taiwan.Market of Pharmaceutical Industry,127,34-36.
21. LaPointe, N. M.,J. G. Jollis(2003).Medication errors in hospitalized cardiovascular patients.Archives of Internal Medicine,163,1461-1466.
22. Leape, L. L.,D. W. Bates,D. J. Cullen,J. Cooper,H. J. Demonaco,T. Gallivan,R. Hallisey,J. Ives,N. Laird,G. Laffel,R. Nemeskai,L. A. Petersen,K. Porter,D. Servi,B. F. Shea,S. D. Small,B. J. Sweitzer, B. T. Thompson,M. V. Vliet(1995).Systems analysis of adverse drug events.Journal of the American Medical Association,274,35-43.
23. Lee, C. C.(2002).Taipei, Taiwan,University of Tamkang.
24. Lesar, T. S.,L. Briceland,D. S. Stein(1997).Factors related to errors in medication prescribing.Journal of the American Medical Association,277,312-317.
25. Leversha, A.(1991).An analysis of clinical pharmacist interventions and the role of clinical pharmacy at a regional hospital in Australia.Australian Journal of Hospital Pharmacy,21,222-228.
26. Linstone, H. A.,M. Turoff(1975).The Delphi Method: Techniques and Applications.Massachusetts:Addison-Wesley.
27. Mark, G. S.,E. M. Robert(1997).Probabilistic Risk Assessment of Engineer in Systems.London:Chapman & Hall.
28. Murry, J. W.,J. O. Hammons(1995).Delphi: a versatile methodology for conducting qualitative research.The Review of Higher Education,18,423-436.
29. Phillips, J.,S. Beam,A. Brinker,C. Holquist,P. Honig,L. Y. Lee,C. Pamer(2001).Retrospective analysis of mortalities associated with medications errors.American Journal of Health-System Pharmacy,58,1835-1841.
30. Roberts, D. E.,M. G. Spencer,R. Burfield,S. Bowden(2002).An analysis of dispensing errors in UK hospitals.International Journal of Pharmacy Practice,10,88-96.
31. Roy, V.,G. Paneet,S. Shouryadeep(2006).Medication errors: causes and prevention.Health Administrator,6,60-64.
32. Saaty, T. L.(1980).The Analytic Hierarchy Process.NY:McGraw-Hill.
33. Santell, J. P.,D. Cousins(2004).Preventing medication errors that occur in the home.United States Pharmacy,29,64-68.
34. Santell, J. P.,R. W. Hicks(2005).Medication errors involving geriatric patients.The Joint Commission Journal on Quality and Patient Safety,31,233-238.
35. Santell, J. P.,R. W. Hicks,D. D. Cousins(2005).Technical ReportTechnical Report,Rockville, MD:USP Center for the Advancement of Patient Safety.
36. Santell, J. P.,R. W. Hicks,M. Judy,D. C. Diane(2003).Medication errors: experience of the United States pharmacopeia (USP) medmarx reporting system.Journal of Clinical Pharmacology,43,760-767.
37. Strategies for preventing medication errors through automated technology
38. Teng, J. Y.(2005).Technical ReportTechnical Report,National Taiwan Ocean University, Research Center of Logistics Planning and Management.
39. Tsai, M. C.(2000).Developing public transport safety management and safety regulations by using risk management skills.Transportation Planning Journal,29,181-212.
40. Williams, D. J. P.(2007).Medication error.Journal of the Royal College of Physicians of Edinburgh,37,343-346.
41. Yu, L. H.(2004).Discussion of medication error and improvement.Journal of Chia-Yi Christian Pharmacy Information,49,4-8.