D3-2　Ergonomic Review of the Processes of High-alert Medications for Hospital Inpatients

抄録

Medication error is the most frequent category of errors among others, according to the 2015 annual report of the Taiwan Patient-safety Reporting system (TPR). This type of errors is especially prevalent among hospital inpatients. For those inpatients treated with high-alert medications, any error in their treatments may cause serious adverse outcomes for them. The aim of this study is to review the process of high-alert medications for hospital inpatients with an emphasis on ergonomic perspective. First, a committee was formed consisting of physicians, pharmacists, nurses, and ergonomists. Then, the committee visited four medical institutes to observe their procedures of prescribing, dispensing, and administrating high-alert medications to inpatients. Next, physicians, pharmacists, and nurses in the institutes were interviewed for understanding their daily practices and related issues or problems. Finally, data collected from the observations and interviews were further discussed in the committee to identify room for further improvement in reducing errors and enhancing usability. The observations and interviews focused on the three major stages: physician order entry, pharmacy dispensing, and medication administration. In the stage of physician order entry, Computerized Physician Order Entry (CPOE) systems were used in all the institutes. However, all the systems were different in terms of their functionalities, user interfaces, and databases. Issues about information display, such as the size of order entry window, use of colors and blinks, alert display, and information visualization, were pointed out for further improvement. In the stage of pharmacy dispensing, the major issues were workplace layout and physical environment. Moreover, information could be more visualized. Finally, in the stage of medication administration, multitasking was the common practice and may lead to work overload. Therefore, simplifying procedures or providing aids may improve the work quality of nurses. Furthermore, labels on the medications and the display on the administration devices could be redesigned. Many ergonomic issues were found in the process of high-alert medications for hospital inpatients. These issues could increase mental workload and/or reduce situation awareness of these healthcare practitioners, and consequently might cause errors. In this preliminary study, we identified the problems in the medication process and provided possible solutions. Further empirical research on these identified ergonomic issues in the process of high-alert medications for hospital inpatients should be worthwhile.