ABSTRACT
Now, the prescription safety always has been a key part of patient safety and the human reliability is a key factor of pharmacist performance during prescription in the medicine station. Prescription errors would make patient hurt or death. After 2002, some serious patient safety events happened in Taiwan. The reliability of prescription has been a very trendy topic of conversation. Under the pressure of cost-down from the healthcare insurance company, the number of pharmacists has been minimized in hospitals and the duty of job has been over loaded. The objects of this proposal are using ergonomics approaches to investigate the human reliability at medication workstations. Participates were 51 pharmacists. The used methods were: in-plant survey, ergonomic job analysis, workstation measurement, anthropometry and questionnaires. The incident rate and risk factors of human error of medication processes has been put together to generate advance reengineering device of work environment. Based on the result of self-report questionnaire, I 00% people knew that miss would happened during the prescription prepare processes. There were 93.3% pharmacists thought they had made miss after they had done their jobs, 63% pharmacists made miss during the last 3 months, and 97.8% pharmacists had heard officemates talked about miss in the office room. About what type of jobs were problem maker, 55.1% thought prescription prepare process had highest
miss rate, the next high (20.5%) was pharmacy machine processes, and 11.5 % was bagging process. Based on the Ramussen principle of motion levels of prescription, and the highest probability of miss have been ranked by the 50% pharmacists ofthis study. The sequences ofmiss rates of scopes were regulation (49.0%), technology (31.0%), and knowledge (19.6%). Based on Swain principle to classify the types of miss and the highest probability of miss have been ranked by the 50% pharmacists of this study The miss rates of scopes were task ( 49.0%), loss (25.5%), miss of opportunity (19.6%), and order miss(5.88%) in sequences. Based on error report system of pharmacy, the human reliability of prescription by season from 2004 to 2008, the heighted error rate happened in Oct. 2005 and rate was 0.19% (reliability=99.89%). And, the lowest was 0.057% (reliability=99.943%) in Feb. 2007. During June 2004 ~May 2008, the trend of error rate was decreasing from 0.002 (0.2%) to 0.0005 (0.05%). And, the reliability of preparing prescription was 99.8% to 99.95% by month. Based on the results of this study and subjective self-report, motion in regulation scope and task miss was the major human errors. Pharmacists were very familiar the procedure of their jobs. However, sometimes, they would make mistakes for some reasons in the well-known tasks. It might be carless, miss one or two steps or made un-appropriate decisions.
