用藥疏失不僅可能導致藥物不良事件之發生，亦明顯增加醫療人員的工作負擔，耗費額外的醫療資源。據估計藥物不良事件約28~56%是可以避免的，且大部份發生於處方開立的階段。研究顯示造成處方疏失的主要原因是缺乏藥品及病患的資訊，然而於開立處方時，電子化醫囑輸入系統是一提供藥物及病患資訊之良好工具。國外許多研究已顯示電子化醫囑輸入系統加上藥品警訊的提醒，可以明顯減少用藥疏失的發生、標準化醫療照護的品質、改善醫療照護系統的流程及節省醫療資源。
　　本研究在門診原有診間電子化醫囑輸入系統，建構即時性的藥品警訊，分析藥品警訊系統對醫師處方開立行為的影響，並比較此警訊系統對警訊上線前後處方開立疏失及處方輸入錯誤發生率之改變。於電腦警訊系統正式上線兩個月後進行問卷調查，探討使用者對於此藥品警訊系統之滿意度。
　　本研究中約每處方1000筆藥品即有2.7次警訊出現，醫師對於此藥品警訊有高達58.9%的處方修改率，處方修改的型態以調整頻次最為常見，而醫師不修改處方的理由以病患病情需要佔多數。警訊上線後疑義處方發生率明顯自警訊上線前0.67 /1,000減少為0.43 /1,000（P<0.001）。問卷調查結果顯示，超過六成以上的醫師、藥師及跟診人員滿意各類警訊之設限準則及警訊內容之品質，而超過75%的使用者認為不接受藥品警訊時應勾選理由，亦有九成以上認為此警訊系統可以減少用藥疏失之發生。較多跟診人員（57%）反應藥品警訊系統減慢電腦系統之速度，僅有少部份使用者（27.3~35 %）曾因警訊之出現而覺得干擾。因此，在門診醫囑輸入系統建置藥品警訊是一改善醫師處方行為之良好工具，亦可以有效減少用藥疏失之發生。整體而言，使用者對藥品警訊系統皆持滿意的態度。

　　Medication errors may result in adverse drug events (ADEs), increase the workload of health care professionals, and deplete medical resources. Twenty-eight percent to 56% of ADEs are judged to be preventable and most commonly to occur during medication prescribing. The common factors associated with prescribing errors are inadequate provision of drug knowledge and patient information. A computerized physician order entry system（CPOE）is a great tool to provide drug and patient information at the time orders are prescribed. Many studies have demonstrated that CPOE with medication alerts may reduce medication errors, provide standardization of care and improve efficiency of care delivery and costs saving.
　　This study developed a real time medication alert system in original computerized order entry system at the outpatient department. The impacts of medication alert system on physician’s prescribing practices were evaluated. A prospective before-after comparison was carried out to assess the effects of the alert system in reducing the number of prescribing and transcribing errors. After two months of intervening medication alert system in practice, we conducted questionnaire survey to evaluate the user’s satisfaction.
　　During the study, 0.27% of prescriptions triggered the alert. Among the alerted prescriptions, 58.9% were revised and administering frequency was the most frequent revisions. On the other hand, major reason to override the drug alert was “Justification of patient’s condition”. In comparison with pre-intervention period, the prescribing and transcribing error rate dropped from 0.67 per 1000 medications to 0.43 per 1000 medications（P<0.001）after intervention. The results of questionnaire survey revealed that over 60% of physicians, pharmacists and clerks agreed with the criteria and quality of the medication alert system. More than 75% of users considered that it shluld be compulsary to remark the reason for overriding drug alerts, and over 90% had confidence on the alert system to reduce medication errors. Fifty-seven % of the clerks commented that medication alerts slow down the computer processing of orders. However, some users （27.3~35%） felt annoyed while alerts appeared.
　　In conclusion, computerized order entry with medication alert is an effective tool for improving physician prescribing practices and substantially decreases the rate of prescribing and transcribing errors. Overall, users are satisfied with the medication alert system.

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