Although the computerized physician order entry (CPOE) with clinical decision support (CDS) system decreased many medication errors, some new forms of error appeared after implementation of CPOE and CDS.  We used the failure mode, effect, and criticality analysis (FMECA) method to review all the steps of our inpatient medication use process, adopt improvement strategy and re-evaluate its effect.  In the step of physician ordering, medication verification by another physician simultaneously through electronic message during keying orders was adopted.  We adopted Barcode medication verification during the process of validation by pharmacist.  In the step of nurse medication administration, Barcode patient and medication verification during medication administration was adopted.  The total criticality index (CI) values of 17 failure modes decreased from 3000 to 1490 after intervention, and for 11 out of 17 failure modes the CI was smaller.  Through the FMECA, it was found that the Barcode medication verification can improve the safety of inpatient medication use process.

雖然使用電子醫囑給藥及臨床決策輔助系統大大降低了給藥錯誤，但是卻出現了一些新的錯誤型式。我們使用失效模式及危急效應分析方法來檢視所有住院用藥流程，採取改善對策，再重新評估其效果。在醫生開立處方部份，我們採取醫囑開立時，同步傳簡訊至主治醫師的手機，讓主治醫師確認處方。在藥師審核處方部份，我們採取藥師必須使用電腦條碼確認處方後再審核。在護理人員給藥部份，我們採取護理人員必須使用電腦條碼確認病人及處方後才能給藥。十七個失效模式在改善對策後，加總危險係數由改善前的3000降到1490，且共有十一個失效模式危險係數下降。經由我們的失效模式及危急效應分析方法，我們採取電腦條碼確認處方，同時改善住院用藥流程的安全性。