本研究利用案例研究醫院藥劑部門診調劑疏失通報系統內的資料，初步統計分析發現調劑疏失的類別以藥品錯誤(藥品選取、劑量、劑型)(51.5%~54.4%)占最多，其次是數量錯誤(25.1%~30.7%)；因為調劑疏失的發生可分為「人」與「系統」兩部份，本研究以探討「系統」疏失為主，嘗試瞭解藥品外觀、藥品名稱、貯存位置、藥品劑型、劑量與藥理分類對藥品調劑疏失的影響。
本研究以案例研究醫院2006年1-4月門診調劑疏失通報資料，以藥師現場評估藥品包裝相似度(藥品外觀之大小、形狀、顏色)，並利用電腦程式評估藥品名稱拼字相似度-(Trigram-2b)(學名-學名、商品名-商品名、學名-商品名)、藥品名稱拼字標準距離NED(學名-學名、商品名-商品名、學名-商品名)、貯存位置、藥理分類、藥品劑型與劑量。運用卡方獨立性檢定結果：上述13個變數對於調劑疏失皆達顯著。再以列聯係數來看各個調劑疏失風險因素與調劑疏失兩者間關聯強度，也皆達顯著；並以羅吉斯迴歸分析透過建模結果得知：藥品形狀、藥品貯存位置、藥品藥理分類、藥品劑型、藥品學名拼字相似度、藥品商品名拼字相似度、藥品學名商品名拼字標準距離等七個變數相較其他變數而言，在預測調劑疏失發生上較具重要性，且建構的模式預測力達74.44%，正確率為84%，結果算不錯。
本研究證明了藥品外觀包裝(大小、形狀、顏色) 、藥品名稱(學名、商品名)拼字相似度及標準編輯距離、藥品貯存位置、藥品藥理分類、藥品劑量、劑型等，均為藥品調劑的風險因素。期望日後每一新藥能放入模式測試，若得到的發生率過高者則擬訂改善措施，例如外形相近者分開存放；口服調配區藥品標示以顏色區分；藥品品名雷同者在藥品資料建檔時以大小寫編輯藥名；同成份不同劑量或劑型者：藥名後顯示劑量或劑型再加商品名，以避免調劑疏失。

Background: From assess the data of dispensing errors of the ambulatory Pharmacy in a teaching hospital, the early results show that primary dispensing errors are dispensing wrong medication (51.5%~54.4%) (e.g., medication selection, dosage form, dose).The second type of dispensing errors is quantity dispensed (25.1%~30.7%). The dispensing error problem can classify two parts, such as “person” and “system”. This study focused on system approach and tried to understand the impact on dispensing errors from the package of medication, drug name, and the storage, dosage form, dose and the classification of pharmacology.
Methods: Retrospective 4–month period from January-April 2006 in an ambulatory pharmacy of the teaching hospital in Taiwan. The pharmacist evaluated the package of medication (shape, size, and color), and utilize the computer to assess the drug name (generic name & trade name) orthographic similarity–(trigram-2b), drug name (generic name & trade name) orthographic normalized edit distance(NED), the classification of pharmacology ,dosage form and dose.
Result: Relationships between the 13 variables and dispensing errors were investigated using the Chi-square test, with a p value below 0.05 considered statistically significant. Setting the model by Logistic Regression analysis that recognized the seven variables: the package of medication shape, the storage, drug name (generic name & trade name) orthographic similarity-(trigram-2b), drug name (generic name & trade name) orthographic normalized edit distance (NED), dosage form, dose and the classification of pharmacology are more important than other variables (risk factors) for predicting dispensing errors. The seven-variable model had good predicted value (74.4%); the accuracy rate is 84%.
Conclusion: This study identified the package of medication (shape, size, and color), the storage, drug name (generic name & trade name) orthographic similarity, drug name (generic name & trade name) orthographic normalized edit distance, dosage form, dose and the classification of pharmacology are the risk factors for dispensing errors.

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