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系統識別號 U0007-2907201116495100
論文名稱(中文) 兒科醫令警示系統於預防藥物疏失之成效
論文名稱(英文) Impact of Computerized Physician Order Entry with Alert System on Preventing Pediatric Medication Errors
校院名稱 臺北醫學大學
系所名稱(中) 藥學研究所
系所名稱(英) Graduate Institute of Pharmacy
學年度 99
學期 2
出版年 100
研究生(中文) 侯靜怡
研究生(英文) Jing-Yi Hou
學號 M301098031
學位類別 碩士
語文別 中文
口試日期 2011-06-30
論文頁數 71頁
口試委員 委員-何蘊芳
委員-吳姿樺
指導教授-陳香吟
中文關鍵字 兒科  醫令  劑量  藥物疏失  警示系統 
英文關鍵字 Pediatric  Computerized Physician Order Entry  dosage  Medication Errors  Alert System 
學科別分類
中文摘要 兒童並不是成熟的個體,其獨特的藥品動態學及藥物藥效學,與成人相比明顯的不同。因此兒童使用藥物有其獨特性,也容易因藥物疏失而受到傷害。曾有研究指出,潛在性藥物不良反應在兒童的發生率比成人高於三倍。兒童也因為一些危險因子,例如短時間內體重改變快速、以體重計算劑量及缺乏溝通等因素,使得兒童更容易面臨藥物疏失的發生。

  本研究為橫斷性研究,研究時間為2010年及2011年一月至三月,對象為北市某醫學中心門診所有18歲以下看診兒童。研究目的是建置一個以兒科為主的電子醫令警示系統,並評估其成效。當醫師開立藥品劑量時,系統評估劑量是否於合理範圍,若是高於或低於系統所設置的建議劑量,會予以警示並同時提供建議劑量。

  結果顯示系統建置前,兒科總處方筆數共72431筆,以系統回溯篩選劑量錯誤筆數偵測筆數共4051筆,醫師處方劑量錯誤發生率為5.6%;系統建置後兒科總處方筆數共80532筆,劑量錯誤筆數共3131筆,醫師處方劑量錯誤發生率為3.9% (p<0.001)。系統建置前,實際偵測到劑量錯誤筆數為16筆,劑量錯誤偵測率僅0.022% ;系統建置後,劑量錯誤實際偵測率增加為3.9% (p<0.001)。另因系統警示而醫師修改劑量使劑量錯誤減少為2698筆,於是至病人端之劑量錯誤發生率由系統建置前5.6%減少為3.4% (p<0.001)。且劑量錯誤減少率也由建置前0.39%至建置後13.4% (p<0.001)。在嚴重度方面,於系統上線前,藥師發藥時共發現2筆潛在致命性錯誤;系統建置後,因經由系統警示14筆致命性錯誤及11筆嚴重錯誤,醫師均已接受系統警示修正,故藥師審查處方時,已無致命性及嚴重錯誤處方。

  兒科醫令警示系統設置於醫師開立處方時,能立即提示醫師修改劑量錯誤。結果顯示系統能顯著偵測劑量錯誤,也可有效減低藥物疏失的發生及嚴重度,增加兒科用藥安全。
英文摘要 Children are more susceptible to medication errors and related injuries due to the significant differences in both pharmacokinetics and pharmacodynamic compared with adults. Potentially harmful medication errors that occurred 3 times more in children than in adult are major concerns in many medical institutions. The weight-base dosing, significant weight changes in short period of time and deficiency of communication with pediatric patients are main factors making children vulnerable to medication errors.

The purpose of this study is to build a standard pediatric dosing recommendations into CPOE (Computerized Physician Order Entry) in order to assist the physician while ordering the pediatric doses. This is a cross-sectional study analysis of outpatient from January to March 2010 and 2011. Patients were eligible for inclusion in the study if they were < 18 years of age. The primary outcome is the incidence of dose prescribing errors and severity.

Before the implementation of CPOE with alert system, dose prescribing errors which were retrospectively detected by alert system, occurred in 4051of 72431(5.6%)prescriptions with the pharmacist-detected 16 (0.022%) errors in all prescriptions. After the implementation of CPOE with alert system, dosing prescribing errors occurred in 3131 of 80532(3.9%, p <0.001), and the alert system detected dose prescribing errors rate of 3.9% which was significantly increased comparing to pharmacist-detected error rate (0.022%;p<0.001) before the implementation of CPOE.
On top of that, adjustment of doses by physician based on the alert system reduced dose-related prescribing error to 2698 errors. The implementation of the system resulted in a significant decline in dose-related medication errors from 5.6% to 3.4% (p<0.001). A significant increasing in rate of decreased dose-related errors was also observed (p<0.001).About the severity of the errors, before the implementation, there were 2 potential lethal errors occurred when the pharmacists were dispensing. With the help of CPOE with alert system, there were 14 potential lethal errors occurred but corrected with the recommendation immediately. Therefore, there were no potential lethal errors detected when the pharmacists were dispensing.

The CPOE with alert system showed the warnings once the errors were detected so that the doctors might change the prescription immediately, which may prevent the dose prescribing errors effectively。The CPOE with alert system can improve patient safety and significantly decreased risk of medication dosing errors.
論文目次 目次
中文摘要 I
英文摘要 III
目次 V
表目錄 VIII
圖目錄 IX
第1章 緒論 1
第2章 文獻探討 2
2.1 小兒藥物治療學 2
2.1.1 藥品動態學 2
2.2 小兒易發生的藥物疏失的原因及改善方法 7
2.2.1 兒科藥物疏失發生率、型態 7
2.2.2 兒科藥物疏失的危險因子 10
2.2.3 藥物疏失的改善方法 16
第3章 研究目的 21
第4章 研究方法 22
4.1 研究設計 22
4.1.1 確定系統藥品清單 22
4.1.2 藥品劑量資料收集 24
4.1.3 系統需求討論 24
4.1.4 系統藥品資料建置 25
4.1.5 系統測試 29
4.1.6 體重更新要求 29
4.1.7 人工判定系統所收集資料 30
4.1.8 名詞定義 33
4.2 統計分析 36
第5章 研究結果 37
5.1警示資料中病人分布 37
5.2系統建置前後兒科劑量錯誤率及修改接受率 38
5.2.1醫師處方劑量錯誤發生率 38
5.2.2劑量錯誤實際偵測率 38
5.2.3至病人端之劑量錯誤發生率 38
5.2.4劑量錯誤減少率 38
5.2.5修改接受率及警示藥品 40
5.3 劑量錯誤之種類、型態及嚴重度 43
5.3.1 系統建置前劑量錯誤種類、型態及嚴重度 43
5.3.2 系統建置後劑量錯誤種類、型態及嚴重度 48
5.4 劑量合理性分析 53
5.4.1 劑量低於建議下限 53
5.4.2 劑量高於建議上限 53
第6章 研究討論及限制 56
6.1系統建置前後兒科劑量錯誤率及修改接受率 56
6.1.1 劑量錯誤偵測率 56
6.1.2 處方修改接受率 58
6.2 劑量錯誤之種類、型態及嚴重度 59
6.3 劑量合理性分析 61
6.3.1 劑量低於建議下限 61
6.3.2 劑量高於建議上限 62
6.4 研究限制 64
6.5 未來展望 65
第7章 結論 66
參考文獻 67
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