| Summary: | 碩士 === 中原大學 === 工業與系統工程研究所 === 101 === Patient safety is always the aim which everyone were concerned,human would get sick, so medicine have seemed important for the patient, furthermore the medicine perfection and completeness would be most important for the patient, and then how could we improve the human reliability of distributed prescription to out-patient clinic is what we want to research. This study was going to find out the process of the distributed prescription which was made an error by human for discussion, as a result we will improve or control each error which won’t happen again, it would let people feel more safety and comfortable when they are taking medicine, and thus diminish caused medical conflicts. The research process have three parts:1)to use Hierarchical Task Analysis (HTA) to build up the standard procedure by observed the workplace in hospital of pharmacists,2)to use Systematic Human Error Reduction and Prediction Approach (SHERPA) to analyze error type and design the questionnaire for distribute at the same time, 3)to use Human Error Assessment and Reduction Technique (HEART) to calculate each movement failure probability and find out which is the most important thing we have to improve. We also give some advice for the hospital.Accroding to the result,the most frequency of the error is Action Error,the second of the error is Checking Error.In the aspect of human error probability,the hightest is 0.386(Reading the prescription information),the next is 0.170(communicate with the doctor when prescription had a problem),the third is 0.164(doctor diagnosis).Dispensing procedure is a complicate and many steps in it,and its aim is going to decrease any probability of human error, it must do a great effort to stop any chance of error happend.Dispensing procedure must check precisely,but some part of procedure is still not insufficiently,it must improve and revise countinuously, the patients could feel safety when using the medicine and decrease the dispensing error or medical dispute.
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