研究限制與未來研究方向

一、研究限制

1. 本研究之標準操作程序設定只能由藥師來進行，並僅測量執行 SOP 的時間，且依定義之合理調劑量時間估算藥師人力，未包含其他相關勤務支援人力，如撥補作業、撕藥袋及藥品運送人力。

2. 本研究得出之合理調劑量時間是由參與實測的 26 家醫院得出之結果，

受限於時間及成本之限制，醫院家數未能依醫院層級之比例來抽樣執行，所得出之各醫院層級的工作量壓力指標結果僅醫學中心與區域醫院代表性較為足夠，地區醫院代表性稍嫌不足，本研究抽樣的地區醫院屬於規模較大的醫事機構，故可能高估其他規模較小地區醫院的藥事調劑工作量。

3. 因各醫院電子化規模程度及藥師本身專業技能有差異，在處方評估部分尚無法確保品質之一致性。

二、未來研究方向

1. 1 本研究之標準操作程序設定只能由藥師來進行，並僅測量依照「標準操作程序」執行的時間，且依定義之合理調劑量時間估算藥師人力，未包含其他非線上作業，如撥補作業、教學研究、行政管理等，故無法外推其餘作業所需之藥事人力，後續研究可增加此部分，讓藥事人力的估算更完整。

2. 本研究受限於時間及成本之限制，醫院家數未能依醫院層級之比例來抽樣執行，地區醫院抽樣的家數較不足，後續研究可藉由增加樣本數的方式讓工作量壓力指標結果更具有代表性。

3. 本研究在處方評估之部分主要是依各醫院配合程度進行實測，病患資訊不盡完整，處方資訊是否足以提供藥師進行處方判讀，並且處方評估與藥師本身技能亦有相關性，後續研究朝處方內容資訊完整性及藥師執業能力現況調查，建立品質指標讓提昇藥事服務品質有實證可依循。

4. 本研究利用主動提問了解病患對於其使用藥品之瞭解程度以進行用藥指導，但病患接受用藥指導與否和其疾病情況及用藥複雜度之相關性尚不明確，後續研究若能著重此部分，並進一步建立標準化諮詢模式，讓藥事服務更符合民眾需求。

給藥事人員之建議：從文獻得知藥品警示系統對用藥安全仍有些許風險，

不可過份倚賴自動化系統評估處方合理性，將重心偏移至完成調劑作業上。若缺乏專業性業務時，藥事人員在醫療團體的角色被漠視，導致對工作的熱忱降低，缺乏知識提升的動力，如此惡性循環的結果，有可能導致藥師整體的專業價值的降低，讓提升藥事服務品質的理想陷入困境。問卷調查部分得知知識不足亦是無法落實處方評估之潛在要素，特別在藥品交互作用、用藥禁忌及需依腎功能調整劑量的藥品等，可藉由持續教育強化相關知識，讓藥師的專業得以發揮，民眾的用藥安全更有保障。病患對於藥品知識需求往往無法具體的顯現，

當藥師也受限於時間因素不採取主動的用藥指導，兩方都處於被動時，就無法有良好的互動，藥師的專業感被淡化，重要性降低，自然也就無法發現其中用藥問題的癥結，更遑論要提昇用藥安全，故主動的用藥指導有其必要性存在。

給醫院經營者的建議：自動化設備系統是以促進病人安全為目的，並非節省人力及成本。文獻證實自動化設備無法取代藥事專業性，同時本研究亦得知自動化調劑設備並無法減少調劑的時間。提升醫療品質整體醫療體系的共同目標，藥師也了解藥事服務品質的重要性，但若無對等的藥事人力，藥師也無餘力去拓展工作範疇。不足的人力使藥師負擔著不合理的工作量，藥師的專業受限於調劑，進而無法扮演好確保用藥安全的角色。

給政策執行者建議：由於醫院評鑑標準的結果促使醫院著重於品質指標的達成，而忽略了結構面之因素。在追求過程面及品質面的結果之前，需確保結構面之因素，要提昇藥事服務品質須仰賴合理的藥事人力配置，鞏固用藥安全及落實藥事專業並無捷徑。另一方面，藥事服務費的給付政策是否與人力需求對等，受限於工作量繁重，相關判斷性服務人力配置往往被醫事機構所忽視而無法有效落實。若有適稱之給付政策，能促使藥事服務的發展更健全，亦可督促藥事人員維持其專業技能，以符合未來民眾及醫事人員的需求及期望。

100

參考文獻

1. 財團法人國家衛生研究院. 全國衛生醫療政策會議總結報告書. 2003.

2. Institute of Medicine of the national academies, 2006. (Accessed Aug 4, 2006, at http://www.oiom.edu.)

3. Hepler C. D., Strand L. M. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm 1990;47(3):533-43.

4. Template for the evaluation of a clinical pharmacist. American College of Clinical Pharmacy. Pharmacotherapy 1993;13(6):661-7.

5. International Pharmaceutical Federation, Standards for Quality of Pharmacy Severice-Good Pharamcy Practice., 1997. (Accessed Aug 4, 2006, at

http://www.fip.org.)

6. Ontario College of Pharmacists, Standard of Practice. 2003. (Accessed Sep 13, 2006, at http://www.ocpinfo.com.)

7. 譚延輝. 藥事經濟學入門: 九州圖書文物有限公司; 2000.

8. Santell J. P., Hicks R. W., McMeekin J., Cousins D. D. Medication errors:

experience of the United States Pharmacopeia (USP) MEDMARX reporting system. J Clin Pharmacol 2003;43(7):760-7.

9. Hickman D, Severance S, Feldstein A. The effect of health care working conditions on patient safety. Rockville, MD.: Agency for Healthcare Research and Quality; 2003.

10. Kistner U. A., Keith M. R., Sergeant K. A., Hokanson J. A. Accuracy of

dispensing in a high-volume, hospital-based outpatient pharmacy. Am J Hosp Pharm 1994;51(22):2793-7.

11. Peterson G. M., Wu M. S., Bergin J. K. Pharmacist's attitudes towards dispensing errors: their causes and prevention. J Clin Pharm Ther 1999;24(1):57-71.

12. 高雅慧、林慧玲. 期待衛生署提升醫療品質的聲明不要跳票─發揮藥事專業要有人力規定做保障. 民生報 2006. 04.16.

101

13. 楊浚琦. 醫學中心門診用藥指導現況和需求性分析及急症患者用藥指導的成效評估. 藥學研究所 1995;國立台灣大學:碩士: 108 頁.

14. Advancing pharmacy practice through research: a 2004 perspective. J Am Pharm Assoc (Wash DC) 2004;44(5):621-8.

15. 財團法人台灣醫療改革基金會. 財團法人台灣醫療改革基金會會訊. 2006;15 期.

16. ASHP guidelines on preventing medication errors in hospitals. Am J Hosp Pharm 1993;50(2):305-14.

17. Kelly K., Safety cannot be sacrificed for speed. 2005. (Accessed Aug 4, 2006, at http://www.pharmacytimes.com.)

18. Fritsch M. A., Lamp K. C. Low pharmacist counseling rates in the Kansas City, Missouri, metropolitan area. Ann Pharmacother 1997;31(9):984-91.

19. Gurwitz J. H., Field T. S., Harrold L. R., Rothschild J., Debellis K., Seger A. C., Cadoret C., Fish L. S., Garber L., Kelleher M., Bates D. W. Incidence and

preventability of adverse drug events among older persons in the ambulatory setting.

JAMA 2003;289(9):1107-16.

20. Kaushal R., Bates D. W., Landrigan C., McKenna K. J., Clapp M. D., Federico F., Goldmann D. A. Medication errors and adverse drug events in pediatric inpatients.

JAMA 2001;285(16):2114-20.

21. Young D. Shortage of pharmacists may have contributed to patient's death. Am J Health Syst Pharm 2002;59(21):2042, 4-5.

22. 優良藥品調劑作業規範. 2001

23. American Pharmacists Association, Improving Medication Use. Advancing Patient Care., 2003. (Accessed Sep 14, 2006, at http://www.aphanet.org/.)

24. American Pharmacists Association, Pharmacist Practice Activity Classification.

2006. (Accessed Sep 14, 2006, at

http://www.aphanet.org/AM/Template.cfm?Section=Search&template=/CM/HTMLD

102

isplay.cfm&ContentID=2908.)

25. ASHP guideline: minimum standard for pharmaceutical services in ambulatory care. American Society of Health-System Pharmacists. Am J Health Syst Pharm 1999;56(17):1744-53.

26. ASHP, The medication-Use-System Safety strategy. 2001. (Accessed Sep 25, 2006, at http://www.ashp.org/patient-safety/MS3-1.pdf )

27. Pharmaceutical Society of Australia, Professional Pharmacy Standards version 3.

2006. (Accessed Sep 10, 2006, at http://www.psa.org.au/.)

28. Royal Pharmaceutical Society of Great Britain, Developing and Implement Standard Operating Procedure for Dispensing. 2001. (Accessed Sep 25, 2006, at http://www.rpsgb.org.uk/.)

29. Beso A., Franklin B. D., Barber N. The frequency and potential causes of dispensing errors in a hospital pharmacy. Pharm World Sci 2005;27(3):182-90.

30. Aiken Lewis R. Content Valdity and Reliablity of Single Itmes or Questionnaires.

Educational and Psychological Measurement 1980;40(4):1980.

31. Aiken Lewis R. Three Coefficients for Analyzing the Reliability and Validity of Ratings. Educational and Psychological Measurement 1985;45(1):131-42.

32. 醫療機構現況及醫療服務量統計摘要. 2005. (Accessed 2007/06/01, at http://www.doh.gov.tw/statistic/醫療服務量/94.htm.)

33. 陳瑞瑩. 藥師調劑錯誤之研究. 台北: 臺灣大學; 2005.

34. 鄧維茜. 醫院藥師工作環境與知覺的組織社會心理對發生調劑錯誤之相關.

台北: 臺灣大學; 2006.

35. Schommer J. C., Pedersen C. A., Doucette W. R., Gaither C. A., Mott D. A.

Community pharmacists' work activities in the United States during 2000. J Am Pharm Assoc (Wash) 2002;42(3):399-406.

36. Hawksworth G. M., Corlett A. J., Wright D. J., Chrystyn H. Clinical pharmacy interventions by community pharmacists during the dispensing process. Br J Clin

103

Pharmacol 1999;47(6):695-700.

37. Schneider J. K., Nickman N. A. Improved use of time after structural and staffing changes to an ambulatory care pharmacy. Am J Health Syst Pharm

1998;55(23):2505-8.

38. Moss R. L., Pounders J. N. Impact of computerization on dispensing time in an ambulatory-care pharmacy. Am J Hosp Pharm 1985;42(2):309-12.

39. Schommer J. C., Pedersen C. A., Gaither C. A., Doucette W. R., Kreling D. H., Mott D. A. Pharmacists' desired and actual times in work activities: evidence of gaps from the 2004 National Pharmacist Workforce Study. J Am Pharm Assoc (Wash DC) 2006;46(3):340-7.

40. Oh Y., McCombs J. S., Cheng R. A., Johnson K. A. Pharmacist time

requirements for counseling in an outpatient pharmacy. Am J Health Syst Pharm 2002;59(23):2346-55.

41. Pierce R. A., 2nd, Rogers E. M., Sharp M. H., Musulin M. Outpatient pharmacy redesign to improve work flow, waiting time, and patient satisfaction. Am J Hosp Pharm 1990;47(2):351-6.

42. Svarstad B. L., Bultman D. C., Mount J. K. Patient counseling provided in community pharmacies: effects of state regulation, pharmacist age, and busyness. J Am Pharm Assoc (2003) 2004;44(1):22-9.

43. Kuyper A. R. Patient counseling detects prescription errors. Hosp Pharm 1993;28(12):1180-1, 4-9.

44. Fahey T., Schroeder K., Ebrahim S. Interventions used to improve control of blood pressure in patients with hypertension. Cochrane Database Syst Rev

2006(4):CD005182.

45. Yuan Y., Hay J. W., McCombs J. S. Effects of ambulatory-care pharmacist consultation on mortality and hospitalization. Am J Manag Care 2003;9(1):45-56.

46. Institute of Medicine. Preventing Medication Errors. In: Philip Aspden JAW, J.

Lyle Bootman, Linda R. Cronenwett, ed.: Washington, DC: National Academy Press;

104

2007.

47. Medication Errors: Prevention and Reduction Guidelines. Board PEIP, 2004.

(Accessed Sep 28, 2006, at http://www.napra.org/docs/0/203/260/284.asp.) 48. North Carolina Board of Pharmacy Statement The Board of North Carolina Pharmacy, 1997. (Accessed Sep 22, 2006, at

http://www.usalaw.com/a-mpNC-PharmacyBoardworkload.html.)

49. Akaho E., MacLaughlin E. J., Takeuchi Y. Comparison of prescription reimbursement methodologies in Japan and the United States. J Am Pharm Assoc (Wash DC) 2003;43(4):519-26.

50. 彼得．聖吉. 第五項修練: 天下文化; 2004.

51. Klein E. G., Santora J. A., Pascale P. M., Kitrenos J. G. Medication cart-filling time, accuracy, and cost with an automated dispensing system. Am J Hosp Pharm 1994;51(9):1193-6.

52. Eslami S., Abu-Hanna A., de Keizer N. F. Evaluation of Outpatient

Computerized Physician Medication Order Entry Systems: A Systematic Review. J Am Med Inform Assoc 2007;14(4):400-6.

53. Schirm E., Tobi H., de Vries T. W., Choonara I., De Jong-van den Berg L. T.

Lack of appropriate formulations of medicines for children in the community. Acta Paediatr 2003;92(12):1486-9.

54. Standing J. F., Khaki Z. F., Wong I. C. Poor formulation information in published pediatric drug trials. Pediatrics 2005;116(4):e559-62.

55. 林慧玲. 嬰仔穿大人鞋小兒用藥還要錯多久？. 民生報 2006. 04.10.

56. Pedersen C. A., Schneider P. J., Scheckelhoff D. J. ASHP national survey of pharmacy practice in hospital settings: monitoring and patient education--2006. Am J Health Syst Pharm 2007;64(5):507-20.

57. Wiederholt J. B., Clarridge B. R., Svarstad B. L. Verbal consultation regarding prescription drugs: findings from a statewide study. Med Care 1992;30(2):159-73.

58. Schommer J. C., Wiederholt J. B. Pharmacists' views of patient counseling.

105

1994;NS34(7):46-53.

59. Wen M. F., Lin S. J., Yang Y. H., Huang Y. M., Wang H. P., Chen C. S., Wu F. L.

Effects of a national medication education program in Taiwan to change the public's perceptions of the roles and functions of pharmacists. Patient Educ Couns

2007;65(3):303-10.

60. Willison D. J., Muzzin L. J. Workload, data gathering, and quality of community pharmacists' advice. Med Care 1995;33(1):29-40.

106

附件一藥事作業規範與用藥安全綜論

藥藥事事作作業業規規範範與與與

用用藥藥安安全全綜綜論論

指導：行政院衛生署

編輯：成功大學臨床藥學研究所

目錄

本文……….………1 參考文獻... i 附錄一優良藥品調劑作業規範... iv 附錄二節錄 FIP Statement of Professional Standards on Medication Errors

Associated with Prescribed Medication... xi 附錄三節錄 ISMP—Pathway for Medication Safety: Evaluation Tool for

Pharmacists ... xiii 附錄四 NCC MERP—Recommendations to Enhance Accuracy of

Dispensing Medications... xix 附錄五 APhA—Pharmacist Practice Activity Classification... xxi 附錄六 ASHP—The medication use system safety strategy...xliii 附錄七節錄 PSA—Professional practice standards... liv 附錄八節錄 RPSGB—Developing and implementing SOP for dispensing ... lxi

素，利用 workload、dispensing error 為關鍵字，於 Pubmed、美國衛生系統藥師協會（ American of Society Health-System Pharmacist; ASHP）、美國藥師聯合會（ American Pharmacists Association; APhA）、加拿大國家藥學法規管理局（ The National Association of Pharmacy Regulatory Authorities; NAPRA）、澳洲藥品協會（Pharmaceutical Society of Australia; PSA ）、英國皇家藥學會

（ Royal Pharmaceutical Society of Great Britain; RPSGB）等網站進行搜尋，發現有許多研究以處方調劑量作華島藥學會（Prince Edward Island Pharmacy Board; PEIPB）建議在獨立作業下，藥師調劑之藥品數平均宜為 10 項/小時；在技術員協助下，可達 15~20 項 / 小時。 ² 澳洲藥學會

（Australian Pharmacy Board）的準則建議安全的處方調劑量為 12-15 項／

Argus、MedStation、Sure-Med Unit Dose Center and Sure-Med Dispensing Center、SelecTrac-Rx；中央式的自動化調劑系統則是置於藥局裡，可自動調劑單一劑量的藥品以及 bar-coded 的藥品，例如 Automated Pharmacy Station、ATC-212¹⁰。而自動化調劑系統與調劑疏失也是有關係存在的，在 Pharmaceutical Federation; FIP）是個集合全球藥界組織的協會，於 1912 年成立於荷蘭海牙，至今已超過 90 年，與世界衛生組織（World Health Organization, WHO）係屬法定關係之國際非政府組織（ International Non-governmental Organization with official relationship, INGO ），為 WHO 專業諮詢團體，臺灣藥學會及臨床藥學會均為其團體會員。為使全球各地的藥事執業水準得以善盡

在文檔中合理調劑量與藥事服務品質之探討之研究 (頁 107-200)