研究背景：
近年來，病患安全的議題越來越受到矚目與重視，同屬於醫療團隊的藥師對於掌控用藥安全更是責無旁貸的首要任務。此外，在藥師法、藥品優良調劑作業準則或優良藥品調劑作業規範之中對於藥師在處方確認的步驟中，皆訂定了應遵循的項目。
然而，一位藥師據以評估其手上的處方是否正確、合適且合乎目前法規大多僅能由處方箋上所載的資訊而已。因此，處方上所呈現資訊的完整性，是直接影響藥師執行判斷性服務最重要的因素。除了符合法規規定，對於患者、處方以及藥品方面能夠給予越多元、完整的資訊，對於藥師來說，便能夠有更多的證據來作出最正確的判斷。
此外，想要評估處方的合適性，勢必得要建立一套評估處方的方法，如此一來不僅可以爲處方的合適性設定一個評估的標準，亦可為藥師在評估處方的同時，設定一個堪用的標準作業程序。

研究目的：
建立達成法規暨評估處方合適性必須之處方資訊，並建立處方評估的作業規範。

研究方法：
本研究為橫斷性 (cross-sectional)之描述性 (descriptive) 研究，研究對象為「合理調劑量與藥事服務品質之探討」計畫所收集之處方箋共計1545張。
根據所設定的理想處方項目予以建檔，藉以分析上述處方箋之合法性及完整性並評估現行處方箋對於是否足以提供藥師執行判斷性服務。
此外，也將參照Hanlon氏等所提之評估處方合適性指標：Medication Appropriateness Index (MAI)加以調整，並使用現有處方進行評估，藉以分析抽樣處方之合適程度並推測現行處方合適率，且建立處方合適性的評估指標。

研究結果：
目前所收集的處方多為提供藥劑部門調劑使用之調配單，因此對於符合法令規章方面，如應具備醫師簽章以及管制藥品使用證號等項目是不符合規範的。在臨床判讀需求方面，所收集的處方之中，雖以藥品資訊的提供最為完整，然而相關資訊主要還是用以應付調劑需求。此外，對於藥品劑型、單位含量、給藥途徑等，也有10-15%的處方並未給予完整的資訊。
而使用經修訂MAI準則作為評估處方的方法，可以發現評估藥師們有極高的重測信度 (overall κ=0.762)，但是由於處方資訊的完整性、對於處方的解讀以及每項指標的標準等因素，使得評估信度無法達到完美的等級 (overall κ=0.388)。
分析藥品被評估為不合適的因素，主要是出自於所提供的資訊不齊全，尤其當診斷資訊缺乏時。約90%的不合適處方存在缺乏診斷或診斷資訊不齊全之問題。
關於影響處方合適性部分，除了藥師個人的專業判斷以外，處方上藥品品項的多寡，是影響合適程度最大的因素。

研究結論：
依本研究所收集的處方來看，部分處方所能提供的資訊仍十分有限。
使用經修訂的MAI準則可以提供藥師作為評估處方的標準作業流程，若能為進行評估作業的藥師提供適當的資訊及參考資料，並對於準則中各項指標能夠充分了解且加以完整的教育訓練，如此一來才可確保藥師得以為患者的用藥安全發揮其專業的判斷性服務。

Background：
In recent decade, the issue about patient safety was more emphasized than ever before. Pharmacist, being a member of health care team, plays an important role in ensuring medication safety. During the dispensing process, the information for a pharmacist to evaluate a prescription and perform pharmaceutical care came solely from prescription itself. The integrity of information on the prescription is the key factor for pharmacists to conduct their professional responsibility.

Objective：
To establish a standardized procedure to evaluate a prescription and to assess the appropriateness of prescriptions in Taiwan

Method：
This is a cross-sectional, descriptive study. We collected 1545 prescriptions from secondary and tertiary medical centers all over the Taiwan. The legitimacy of all these prescriptions would be evaluated. We modified the assessment tool from Hanlon’s Medication Appropriateness Index (MAI) for this study.
Ten senior clinical pharmacists were participated in the assessment of prescriptions. The agreement of evaluation process using MAI was also analyzed.

Result：
Most of our collections were dispensing note instead of the original prescriptions, whisch was the common practice in Taiwan. Lack of physicians’ signature and registration number of controlled substance prescribing license were the two major problems in our samples. In addition, there were around 10-15% of prescriptions without inficating the dosage form, streagth and route.
With the modified MAI, we found a highly reliability (overall κ=0.762) amount pharmacist in evaluation a given prescription but the reliability between pharmacists were no convincible(overall κ=0.388).
To analyse the factor of the prescriptions which be assessed to inappropriateness, insufficient information was the main one, principally in diagnosis. About 90% of inappropriateness presciptions had the same problem of insufficient for diagnosis. Besides, the number of medication on the priscription is the key factor to influence the appropriateness of the prescriptions.

Conclusion：
From our study, there was insufficient information in prescription for pharmacist to perform cognitive services, which showed require regulatory intervention to improve the practice.
Well training and sufficient information will provide pharmacist to perform their duties, and fulfill a function of controlling the medication safty.

1.ASHP guideline: minimum standard for pharmaceutical services in ambulatory care. American Society of Health-System Pharmacists. American Journal of Health-System Pharmacy 1999;56:1744-53.
2.Pharmacist Practice Activity Classification. In; 2008. (Accessed at http://www.pharmacist.com/AM/Template.cfm?Section=search&template=/cm/htmldisplay.cfm&contentid=2908.)
3.A.J.Winfield, Richards RME. Pharmaceutical Practice second edition; 1998.
4.藥師法. In; 2007. (Accessed at http://dohlaw.doh.gov.tw/Chi/FLAW/FLAWDAT01.asp?lsid=FL013519.).
5.醫師法. In; 2007. (Accessed at http://dohlaw.doh.gov.tw/Chi/FLAW/FLAWDAT01.asp?lsid=FL013514).
6.藥品優良調劑作業準則. In; 2004. (Accessed at http://dohlaw.doh.gov.tw/Chi/FLAW/FLAWDAT01.asp?lsid=FL033109).
7.Hanlon JT, Schmader KE, Samsa GP, et al. A method for assessing drug therapy appropriateness. J Clin Epidemiol 1992;45:1045-51.
8.Hanlon JT, Schmader KE, Ruby CM, Weinberger M. Suboptimal prescribing in older inpatients and outpatients. J Am Geriatr Soc 2001;49:200-9.
9.Egger SS, Bachmann A, Hubmann N, Schlienger RG, Krahenbuhl S. Prevalence of potentially inappropriate medication use in elderly patients: comparison between general medical and geriatric wards. Drugs Aging 2006;23:823-37.
10.Leventhal JM, Hutchinson TA, Kramer MS, Feinstein AR. An algorithm for the operational assessment of adverse drug reactions. III. Results of tests among clinicians. Jama 1979;242:1991-4.
11.Kramer MS, Leventhal JM, Hutchinson TA, Feinstein AR. An algorithm for the operational assessment of adverse drug reactions. I. Background, description, and instructions for use. Jama 1979;242:623-32.
12.Hutchinson TA, Leventhal JM, Kramer MS, Karch FE, Lipman AG, Feinstein AR. An algorithm for the operational assessment of adverse drug reactions. II. Demonstration of reproducibility and validity. Jama 1979;242:633-8.
13.Naranjo CA, Busto U, Sellers EM, et al. A method for estimating the probability of adverse drug reactions. Clinical Pharmacology & Therapeutics 1981;30:239-45.
14.藥事法. In; 2006. (Accessed at http://dohlaw.doh.gov.tw/Chi/FLAW/FLAWDAT01.asp?lsid=FL013783).
15.Gennaro. Remington's: The Science and Practice of Pharmacy 20/e: Lippincott 2000.
16.III JLF, Vivian JC. Laws Governing Pharmacy. In: Gennaro, ed. Remington's: The Science and Practice of Pharmacy 20/e: Lippincott 2000.
17.管制藥品管理條例施行細則. In; 2003. (Accessed at http://dohlaw.doh.gov.tw/Chi/FLAW/FLAWDAT01.asp?lsid=FL013793).
18.Scott SA. The Prescription. In: Gennaro, ed. Remington's: The Science and Practice of Pharmacy 20/e: Lippincott 2000.
19.M.M.moody. The prescription. In: A.J.Winfield, Richards RME, eds. Pharmaceutical Practice 2/e: Churchill Livingstone 1998.
20.張家嫺, 林素真, 張慧真, 高雅慧. 合理調劑量與藥事服務品質之探討. 國立成功大學 2007.
21.Professional Pharmacy Standards version 3. (Accessed at
22.Developing and implementing standard operating procedures for dispensing. 2007. (Accessed at http://www.rpsgb.org.uk/.)
23.Budnitz DS, Layde PM. Outpatient drug safety: new steps in an old direction. Pharmacoepidemiol Drug Saf 2007;16:160-5.
24.Grissinger MC, Kelly K. Reducing the risk of medication errors in women. J Womens Health (Larchmt) 2005;14:61-7.
25.Maio V, Pizzi L, Roumm AR, et al. Pharmacy utilization and the Medicare Modernization Act.[see comment]. Milbank Q 2005;83:101-30.
26.Mangino PD. Role of the pharmacist in reducing medication errors. J Surg Oncol 2004;88:189-94.
27.Schnipper JL, Kirwin JL, Cotugno MC, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med 2006;166:565-71.
28.譚延輝. 藥師與判斷性服務: 九州圖書文物有限公司; 2003.
29.Andersen M. Is it possible to measure prescribing quality using only prescription data? Basic Clin Pharmacol Toxicol 2006;98:314-9.
30.Avorn J. The prescription as final common pathway. Int J Technol Assess Health Care 1995;11:384-90.
31.Bregnhoj L, Thirstrup S, Kristensen MB, Bjerrum L, Sonne J. Prevalence of inappropriate prescribing in primary care. Pharm World Sci 2007;29:109-15.
32.Barber N, Bradley C, Barry C, Stevenson F, Britten N, Jenkins L. Measuring the appropriateness of prescribing in primary care: are current measures complete? J Clin Pharm Ther 2005;30:533-9.
33.Britten N, Jenkins L, Barber N, Bradley C, Stevenson F. Developing a measure for the appropriateness of prescribing in general practice. Qual Saf Health Care 2003;12:246-50.
34.Spinewine A, Schmader KE, Barber N, et al. Appropriate prescribing in elderly people: how well can it be measured and optimised? Lancet 2007;370:173-84.
35.Brook RH. Quality-can we measure it. N Engl J Med 1977;296:170-2.
36.Higashi T, Shekelle PG, Adams JL, et al. Quality of Care Is Associated with Survival in Vulnerable Older Patients. Ann Intern Med 2005;143:274-81.
37.Lilford R, Mohammed MA, Spiegelhalter D, Thomson R. Use and misuse of process and outcome data in managing performance of acute medical care: avoiding institutional stigma. The Lancet 2004;363:1147-54.
38.Pronovost PJ, Nolan T, Zeger S, Miller M, Rubin H. How can clinicians measure safety and quality in acute care? The Lancet 2004;363:1061-7.
39.Campbell SM, Cantrill JA. Consensus methods in prescribing research. Journal of Clinical Pharmacy and Therapeutics 2001;26:5-14.
40.Anderson GM, Beers MH, Kerluke K. Auditing prescription practice using explicit criteria and computerized drug benefit claims data. Journal of Evaluation in Clinical Practice 1997;3:283-94.
41.Shelton PS, Fritsch MA, Scott MA. Assessing medication appropriateness in the elderly: a review of available measures. Drugs Aging 2000;16:437-50.
42.Steinman MA, Rosenthal GE, Landefeld CS, Bertenthal D, Sen S, Kaboli PJ. Conflicts and concordance between measures of medication prescribing quality. Med Care 2007;45:95-9.
43.Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts.[see comment][erratum appears in Arch Intern Med. 2004 Feb 9;164(3):298]. Arch Intern Med 2003;163:2716-24.
44.Beers MH. Explicit criteria for determining potentially inappropriate medication use by the elderly. An update. Arch Intern Med 1997;157:1531-6.
45.Beers MH, Ouslander JG, Rollingher I, Reuben DB, Brooks J, Beck JC. Explicit criteria for determining inappropriate medication use in nursing home residents. UCLA Division of Geriatric Medicine. Arch Intern Med 1991;151:1825-32.
46.Kunin CM. Inappropriate Medication Use in Older Adults: Does Nitrofurantoin Belong on the List for the Reasons Stated? Arch Intern Med 2004;164:1701-.
47.Hawes C, Morris JN, Phillips CD, Mor V, Fries BE, Nonemaker S. Reliability estimates for the Minimum Data Set for nursing home resident assessment and care screening (MDS). Gerontologist 1995;35:172-8.
48.Samsa GP, Hanlon JT, Schmader KE, et al. A summated score for the medication appropriateness index: development and assessment of clinimetric properties including content validity. J Clin Epidemiol 1994;47:891-6.
49.Kassam R, Martin LG, Farris KB. Reliability of a modified medication appropriateness index in community pharmacies. Ann Pharmacother 2003;37:40-6.
50.Farrell B, Pottie K, Woodend K, et al. Developing a tool to measure contributions to medication-related processes in family practice. J Interprof Care 2008;22:17-29.
51.Rossi MI, Young A, Maher R, et al. Polypharmacy and health beliefs in older outpatients. Am J Geriatr Pharmacother 2007;5:317-23.
52.Steinman MA, Landefeld CS, Rosenthal GE, Berthenthal D, Sen S, Kaboli PJ. Polypharmacy and prescribing quality in older people.[see comment]. J Am Geriatr Soc 2006;54:1516-23.
53.Spinewine A, Dumont C, Mallet L, Swine C. Medication appropriateness index: reliability and recommendations for future use. J Am Geriatr Soc 2006;54:720-2.
54.Hajjar ER, Hanlon JT, Sloane RJ, et al. Unnecessary drug use in frail older people at hospital discharge. J Am Geriatr Soc 2005;53:1518-23.
55.Bregnhoj L, Thirstrup S, Kristensen MB, Sonne J. Reliability of a modified medication appropriateness index in primary care. Eur J Clin Pharmacol 2005;61:769-73.
56.Wong I, Campion P, Coulton S, et al. Pharmaceutical care for elderly patients shared between community pharmacists and general practitioners: a randomised evaluation. RESPECT (Randomised Evaluation of Shared Prescribing for Elderly people in the Community over Time) [ISRCTN16932128]. BMC Health Serv Res 2004;4:11.
57.Hanlon JT, Artz MB, Pieper CF, et al. Inappropriate medication use among frail elderly inpatients. Ann Pharmacother 2004;38:9-14.
58.Goulding MR. Inappropriate medication prescribing for elderly ambulatory care patients. Arch Intern Med 2004;164:305-12.
59.Talerico KA. A Critique of Research Measures Used to Assess Inappropriate Psychoactive Drug Use in Older Adults. J Am Geriatr Soc 2002;50:374-7.
60.Fitzgerald LS, Hanlon JT, Shelton PS, et al. Reliability of a modified medication appropriateness index in ambulatory older persons.[see comment]. Ann Pharmacother 1997;31:543-8.
61.Schmader K, Hanlon JT, Weinberger M, et al. Appropriateness of medication prescribing in ambulatory elderly patients. J Am Geriatr Soc 1994;42:1241-7.
62.Schmader KE, Hanlon JT, Landsman PB, Samsa GP, Lewis IK, Weinberger M. Inappropriate prescribing and health outcomes in elderly veteran outpatients.[see comment]. Ann Pharmacother 1997;31:529-33.
63.Kundel HL, Polansky M. Measurement of Observer Agreement. Radiology 2003:2282011860.
64.Feinstein AR, Cicchetti DV. High agreement but low Kappa: I. the problems of two paradoxes. J Clin Epidemiol 1990;43:543-9.
65.Cicchetti DV, Feinstein AR. High agreement but low kappa: II. Resolving the paradoxes. J Clin Epidemiol 1990;43:551-8.
66.Landis JR, Koch GG. The Measurement of Observer Agreement for Categorical Data. Biometrics 1977;33:159-74.
67.Lambert BL, Lin S-J, Tan H. Designing safe drug names. Drug Safety 2005;28:495-512.
68.Schulmeister L. Look-alike, sound-alike oncology medications. Clin J Oncol Nurs 2006;10:35-41.
69.Jacobs B. Electronic medical record, error detection, and error reduction: a pediatric critical care perspective. Pediatric Critical Care Medicine 2007;8:S17-20.
70.Donovan MD. Sex and racial differences in pharmacological response: effect of route of administration and drug delivery system on pharmacokinetics. J Womens Health (Larchmt) 2005;14:30-7.
71.Anderson GD. Sex and racial differences in pharmacological response: where is the evidence? Pharmacogenetics, pharmacokinetics, and pharmacodynamics. J Womens Health (Larchmt) 2005;14:19-29.
72.Munar MY, Singh H. Drug dosing adjustments in patients with chronic kidney disease. Am Fam Physician 2007;75:1487-96.
73.RK K. DRUGDEX (R) System. In: Thomson Micromedex; 2007.
74.Lacy CF, Armstrong LL, Goldman MP, Lance LL. Drug Information Handbook. 13th ed; 2005-2006.
75.Aronoff GR, Bennett WM, Berns JS, et al. Drug Prescribing in Renal Failure. fifth ed; 2007.
76.Ambrosio AF, Soares-Da-Silva P, Carvalho CM, Carvalho AP. Mechanisms of action of carbamazepine and its derivatives, oxcarbazepine, BIA 2-093, and BIA 2-024. Neurochem Res 2002;27:121-30.
77.Schmidt D, Elger CE. What is the evidence that oxcarbazepine and carbamazepine are distinctly different antiepileptic drugs? Epilepsy Behav 2004;5:627-35.
78.McLean M. Oxcarbazepine: mechanism of action. In: Levy RH, Mattson RH, Meldrum BS, Perucca E, eds. Antiepileptic drugs. 5th ed. Philadelphia Lippincott Williams & Wilkins; 2002:451–8.
79.RC S, T G, J W, M B, A B, J DS. Differential efficacy of oxcarbazepine and carbamazepine during adjunctive therapy in children with refractory partial seizures. Epilepsia 2002;43.
80.Burke A, Smyth E, FitzGerald GA. Analgesic-Antipyretic and Antiinflammatory Agents; Pharmacotherapy of Gout. In: Brunton LL, ed. Goodman & Gilman's The Pharmacological Basis of Therapeutics: McGraw-Hill 2006.
81.藥物、醫療器材、化妝品許可證查詢作業. In;2008. (Accessed at http://203.65.100.151/DO8180.asp.)
82.G6PD Deficiency Association. (Accessed at http://www.g6pd.org/favism/english/index.mv?pgid=myhome.)
83.Drover DR. Comparative pharmacokinetics and pharmacodynamics of short-acting hypnosedatives: zaleplon, zolpidem and zopiclone. Clin Pharmacokinet 2004;43:227-38.
84.Terzano MG, Rossi M, Palomba V, Smerieri A, Parrino L. New drugs for insomnia: comparative tolerability of zopiclone, zolpidem and zaleplon. Drug Saf 2003;26:261-82.
85.Hesse LM, von Moltke LL, Greenblatt DJ. Clinically important drug interactions with zopiclone, zolpidem and zaleplon. CNS Drugs 2003;17:513-32.
86.Hajak G, Muller WE, Wittchen HU, Pittrow D, Kirch W. Abuse and dependence potential for the non-benzodiazepine hypnotics zolpidem and zopiclone: a review of case reports and epidemiological data. Addiction 2003;98:1371-8.
87.Holm KJ, Goa KL. Zolpidem: an update of its pharmacology, therapeutic efficacy and tolerability in the treatment of insomnia. Drugs 2000;59:865-89.