背景：
醫療服務品質攸關病人生命安全 ， 如何 確 保高 品質的藥事服務，是為藥事人員，所必須去追求的 。本研究導 入六 個標 準 差（six sigma 或簡稱 6σ）的品質 管理方式，來改善門診藥師調劑 錯誤率，並提供同業們更多品質 改善應用之方法。
方法：
研究小組應用六個標準差之五大步驟 DMAIC（定義期、衡量 期、分析期、改善期、監控期）， 將門診自調劑至發藥之流程品質進行不斷監測與改善，依不同時期之指標來進行監測，確保病 患用藥安全。
結果：
藉由QFD評分結果，確立改善目標。利用 FMEA 技術分析出可能致藥師調劑錯誤之原因為：藥名相似、外觀相似、同成 分不同劑量、位置相鄰。改善後 統 計門診藥師調劑錯誤率內部監測指標已達五 個標 準差 之 目 標，調劑發藥外部監測指標為六 個標準差之目標。
結論：
確保病患用藥安全，調劑錯誤率 應為零，吾人可採用不同之品質 改善方式來降低調劑錯誤率，六 個標準差為更嚴謹且為醫藥界少用之工具，藉由本研究提供其 他醫療院所參考。
Background：
The quality of health care system is highly correlated with patients’safety. Pharmacists have a responsibility to ensure and improve the quality of pharmaceutical care service. The aim of this study is to improve pharmacist dispensing error by implementing six sigma technique in order to achieve “zero defect” in dispensing process.
Methods：
By using DMAIC (Define, Measure, Analyze, Improve , Control), is a performance improvement model of six sigma, the project team continuous to improve the dispensing errors occurred in the outpatient clinic to ensure patients’ safety.
Results：
Quality function deployment (QFD) was used to define the goals of the improvement activity. The failure modes caused pharmacist
disensing error were identified by FMEA (Failure mode and effect analysis, including looks-alike drug names, sounds alike drugs, same ingredients with different strength. Statistical data showed that disensing errors were improved after the improvement activity. Five sigma and six sigma were selected as a threshold indicator of the dispensing error and delivery drugs to patients respectively.
Conclusions：
To ensure patients’ drug safety, zero defects should be required as an ulimate goal to be achieved in the process of pharmacist dispensing.
