八、此錯誤對受訪者的影響?
發生藥師錯誤後,對於受訪者的影響幾乎都是日後會比較小心並警惕自己,希望不 要再犯同意的錯誤。如 A:「就是比較小顆的藥,就是 check 的時候會把它拿出來看到 底是什麼。」B:「就會比較警惕自己啊,比較小心一點,不要發生錯誤這樣。」C:「拿 到那個藥的時候比較膽顫心驚…可能會多瞄幾眼吧。」D:「對我,check 要更小心一點,
尤其是你覺得容易錯的,一定要把他翻過來,看到對。」E:「以後就會特別注意了啦,
就是看仔細,即使前面病人在吵,就是不管他,就是請他們乖乖排好隊。」F:「之後當 然是發藥之前都會很謹慎的,再三看過才會發出去。」G:「我是..叫病人要看一下病人 的反應,這是你的名字哦?如果遇到有重複兩個姓名的話,會這樣子。」
九、醫院或藥劑部門是否定期對藥師錯誤進行教育與回饋?
分為三大類,有定期檢討錯誤與進行教育、發生錯誤才進行檢討及完全沒有任何的
教育與回饋。
1.
定期檢討錯誤與進行教育,如 B:「有啊,我們只要發生異常,每個禮拜在開會都 會報出來。」D:「我們每個禮拜都會有問題處方討論,我們會把問題處方簽留下來,發生什麼錯,有一位藥師會統計錯誤有哪一些,哪一些比較多。」F:「就是每個月 都會開一次科內的會議,都要報告有沒有什麼調劑錯誤,它的比率大概佔多少,都 會在科內會議中公佈出來。」
2.
發生錯誤才進行檢討,如 I:「應該說組長他會…如果最近發生什麼錯誤,通常是同 事之間跟組長的反應討論,看要怎麼改進,如果發生什麼事,就會跟組長開個會,看要怎麼改進」
3.
完全沒有任何的教育與回饋,如 C:「我們後來並沒有把這件事情特別提出來,因 為我們那個藥局就很小啊,就 7、8 個人,所以大家都知道這件事,而且那時科內也 沒有討論會。」E:「固定檢討?…只有主任他口頭跟你,口頭會提醒你阿…就是口頭 告誡一下這樣。」G:「以前是沒有啦,差不多都是現場解決。」References
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