二十一世紀的醫療是以病人安全為核心，國內外資料都顯示不良事件類別最多 是由藥品相關問題造成，其中，有三分之二的事件是可以預防的。近幾年國內配合 衛生署推行病人安全目標，鼓勵異常事件通報，對重大異常事件進行根本原因分析，以提昇病人安全成效。所謂根本原因分析是在異常事件發生後，利用品質改善手法及步驟逐步分析，協助組織找出作業流程中及系統設計上的風險或缺點，發現可預防及改善的措施，避免未來類似事件再發生的一種工具。
此用藥疏失案件利用根本原因分析方法進行回溯性分析並謀求改善對策，先以時間序列(tabular timeline)描述事件發生過程，確認問題為『門診藥物劑量錯誤，造成病患服藥過量，昏睡一天半 』，再利用原因樹 (why tree) 分析，找出近端原因 (proximate cause)為資訊系統未及時阻止、人員疏忽、兼任醫師對資訊系統較不熟悉、藥師人力不足等四項。再從近端原因中確認根本原因(root cause)為資訊系統沒有藥物超過最大劑量警示功能，進一步利用屏障分析(barrier analysis)找出可行的對 策為增設資訊系統每次(日)最大極量警示、改變藥師各時段排班人力、獎勵藥師通報用藥疏失、教育藥師問題處方箋與醫師再次核對。經執行相關改善措施後從統計上顯示，極量警示接受度為 97.6%；獎勵通報用藥疏失後，醫囑疏失由改善前每月16 件成長到改善中期 165 件，改善後 65 件。
Healthcare focusing on patient safety oriented in 21st century. According to literature, the major cause of adverse events is due to drug-related problems. Among them, two-thirds of events can be prevented especially those of prescription (56%) and drug administration (34%) errors. For the past few years, the focal policy of Department of Health has forced healthcare providers to launch an institutional patient safety program, encourage reporting adverse events, and further conduct root cause analysis to advance outcomes of patient safety. What so called root cause analysis means that once adverse events happened, the techniques of quality control and stepwise analysis method were applied to find out the defaults and risks of operative process and system design in organizations as well as the prevention and improvement to avoid the potential malpractice in the future.
We used four steps of root cause analysis (RCA) to analyze and improve the medication error. First of all, a tabular timeline was used to describe the process of the events and identify the problem as“overdose prescription in the outpatient department led patients to somnolence for one and a half days”. Second, a why tree analysis was used to find out four proximate causes which encompassed no alarm system, human error, unfamiliar with information system in doctor, and the shortage of pharmacists’ manpower. Third, we confirmed the root cause was no maximum dosage alarm system. Fourth, reactive barrier analysis was used to find out the feasible strategies of implementing maximum dosage alarm system, adjusting pharmacists’ manpower at each shift, rewarding pharmacists in reporting medication errors, and training pharmacists double-check doubtful prescription with doctors.
The result shows that the acceptability of maximum dosage alarm system is 97.6%. The order errors jump from the original 16 cases/month, to 165 cases/month at the improving stage, and then down to 65 cases/month.
