調劑疏失的發生又可分為「人」與「系統」兩部份。本研究將方向定為探討如何調整「作業系統」以改善「人」調劑疏失的機率。企圖瞭解藥品外觀、藥品名稱、貯存位置、藥品劑型、劑量與藥理分類等對藥品調劑疏失的影響。本研究以北部某教學醫院105~106年門診調劑疏失通報紀錄時正本分析架構之可行性。擬分別應用約略集合理論及關聯理論探討一些調劑疏失風險因子對同成分藥品及非同成分藥品調劑疏失兩因素間之決策屬性與關聯情形。最後再比較兩種研究方法的結果。依據實證研究之結果，藥品外觀包裝型態(例如:文字形狀、排裝大小、包裝顏色) 、藥品名稱(成分名、商品名)相似度、藥品調劑貯存位置、藥品的藥理分類、藥品多重劑量、劑型等,均為藥品調劑疏失的因素。依據本實證研究之結果，建議藥品可附加外觀特徵；高低含量者加以「高」「低」警示；改變藥名大小寫;附加藥理提示；調整鄰近位置;中文名標示提前；易混淆警語;加強同仁對於同類藥品的辨識；加入劑型提示；數字大小有所不同;品名相似者外觀印至藥袋上作提示等方案,以達利用系統輔助降低藥品調劑錯誤發生率,來完成提高病患用藥的保障。

Because the occurrence of the dispensing errors can be divided into two parts: "person" and "system",this study explores how to adjust the 「operating system」to improve the probability of 「human 」disorder. Therefore, this study try to understand the influence of appearance of drugs, drug name, storage location, pharmaceutical dosage form, dose and pharmacological classification to dispensing errors. This study is based on the data of dispensing errors notification system in someone north teaching hospital outpatient department between years of 2016 ~ 2017, and we use rough set theory to definite the rules of some risk factors to dispensing errors that those two drugs are the same or not ingredients. Then, this study use association theory to understand the relationship strength between dispensing errors' factors and dispensing errors itself. In addition, finally, we can compare the results in Rough Set throry with the results in Association theory. According to this empirical study, the appearance of the drug packaging (size, shape, color), drug name (generic name, trade name) similarity, drug storage location, drug pharmacological classification, drug dosage, dosage form, etc., are all risk factors of dispensing errors. It is recommened that by this study, medicine bag should be used to add appearance features; high and low dose content medicine to be "high" and "low" warning; change the drug name case; add pharmacological tips; adjust the adjacent location of other. Chinese name can be marked in advance. The warning of easy to confuse is more obvious. Adding the dosage form of tips and bigger letter means larger number of medicine. The warning of similar product appearance is printed on the package for tips and other programs. Besides enforcing coworkers' identification of the same type of drug is very important. By above mention; we can expect to reduce the incidence of drug dispensing errors and to improve the protection of patients with drugs.

1:Abdelhamid, T. S., Everett, J. G., (2000) “Identifying root causes of Construction accidents”, Journal of Construction Engineering and Management, Vol. 126 (1), pp.52-60

2:Agrawal, R., Imieliński, T., & Swami, A. (1993). Mining association rules between sets of items in large databases. Paper presented at the Acm sigmod record.

3:Anca, J. M., (2007) “Multimodal Safety Management and Human Factors:Crossing the Borders of Medical, Aviation, Road and Rail Industries”. Ashgate Publishing, Ltd.

4:Anglin, G. L. (1991). Instructional technology past, present and future. Englewood, CO: Libraries Unlimited Inc.

5:Ashcroft DM, Quinlan P, Blenkinsopp A. Prospective study of the incidence,nature and causes of dispensing errors in community pharmacies Pharmacoepidemiol Drug Saf 2005; 14: 327–32.

6:Ashcroft DM et al. Prospective study of the incidence, nature and causes of dispensing errors in community pharmacies. Pharmacoepidemiol Drug Safety 2005; 14: 327–332.

7:Baddeley, A. D. (1986). Working memory. Oxford: Clarendon Press.Baddeley, A. D. (1990). Human memory: Theory and Practice. Boston, MA:Allyn and Bacon.

8:Baddeley, A. D. (1992). Working memory. Science, 255,556-559.

9:B. Walczak, D.L. Massart, ChemoAC, Pharmaceutical Institute, Vrije UnÍersiteit Brussel, Laarbeeklaan 103, B-1090 Brussels, Belgiumaccepted 1 December 1998

10:Banning D. Help to report near-misses. A study of the rate of medication errors in the dispensary. Pharm Pract 1995; 5: 461–464.

11:Bates, David W; Spell, Nahan; Cullen, David J., et al. The Cost of Advers Drug

12:Bayardo Jr, R. J., & Agrawal, R. (1999). Mining the most interesting rules. Paper presented at the Proceedings of the fifth ACM SIGKDD international conference on Knowledge discovery and data mining.

13:Beso A, Franklin BD, Barber N. The frequency and potential causes of dispensing errors in a hospital pharmacy. Pharm World Sci 2005; 27:182–90.

14:Bower AC. Dispensing error rates in hospital pharmacy. Pharm J 1990; 244:R22–R23.

15:Brooks, K. W. (1979). Delphi technique: Expanding applications. North Central Association Quarterly, 54 (3), 377-385.

16:Chua SS, Wong IC, Edmondson H, Allen C, Chow J, Peacham J, Hill G,Grantham J. A feasibility study for recording of dispensing errors and near misses in four UK primary care pharmacies. Drug Saf 2003; 26: 803–13.

17:Cina JL, Gandhi TK, Churchill W, FanikosJ, McCrea M, Mitton P, Rothschild JM, Featherstone E, Keohane C, Bates DW, Poon EG. How many hospital pharmacy medication dispensing errors go undetected? JtCommJQual Patient Saf 2006; 32: 73–80.

18:Custer, R. L., Scarcella, J. A., & Stewart, B. R. (1999). The modified Delphi technique: A rotational modification. Journal of Vocational and Technical Education, 15 (2), 1-10.

19:Dalkey, N., & Helmer, O. (1963). An experimental application of the Delphi method to the use of experts. Management science, 9(3), 458-467.

20:Dalkey, N. C. (1972). The Delphi method: An experimental study of group opinion. In N. C. Dalkey, D. L. Rourke, R. Lewis, & D. Snyder (Eds.).Studies in the quality of life: Delphi and decision-making (pp. 13-54). Lexington, MA: Lexington Books.

21:Delbecq, A. L., Van de Ven, A. H., & Gustafson, D. H. (1975). Group techniques for program planning. Glenview, IL: Scott, Foresman, and Co.

22:De Smet PA, Denneboom W, Kramers C, Grol R. A composite screening tool formedication reviews of outpatients: general issues with specific examples. Drugs Aging 2007; 24: 733–60

23:Donaldson, Molla S, Corrigan, Janet M Kohn, Linda T To err is human:buildinga safer health system 2000

24:Events in Hospitalized Patients. JAMA.277:307-311,1997

25:Faherty, V. (1979). Continuing social work education: Results of a Delphi survey. Journal of Education for Social Work, 15(1), 12-19.

26:Fayyad, U. M., Piatetsky-Shapiro, G., Smyth, P., & Uthurusamy, R. (1996). Advances in knowledge discovery and data mining (Vol. 21): AAAI press Menlo Park.

27:Gothard AM et al. Using error theory in the pharmacy dispensary can reduce accidents. Pharm Pract 2004: 44–48.

28:Green, K. C., Armstrong, J. S., & Graefe, A. (2007). Methods to elicit forecasts from groups: Delphi and prediction markets compared. Institute of Medicine. Assessing Medical Technologies. Washington, DC: National Academy Press; 1985Institute of Medicine, 1990.

29:I. S. Sanghera, B. D. Franklin and S. DhillonThe attitudes and beliefs of healthcare professionals on the causes and reporting of medication errorsin a UK Intensive care unit 2007, 62, pages 53–61

30:Jacobs, J. M. (1996). Essential assessment criteria for physical education teacher education programs: A Delphi study. Unpublished doctoral dissertation, West Virginia University, Morgantown.

31:James KL et al. Impact of automation on the occurrence of unprevented dispensing incidents at Llandough hospital. Int JPharm Pract 2007;15(suppl. 2): B59.

32:James KL et al. A study of unprevented dispensing incidents inWelsh NHS hospitals. Int J Pharm Pract 2008; 16: 175–188.

33:James KL et al. The incident iceberg: a comparison ofunprevented and prevented dispensing incidents reported byNHS hospitals. Int J Pharm Pract 2008; 16(suppl. 1): A18

34:James KL et al. Development and use of the critical incidenttechnique in evaluating the causes of dispensing incidents Int JPharm Pract 2008; 16:239–249
Kanki, B. G., Helmreich, R. L. and Anca, J. M., (2010) “Crew Resource Management”. Elsevier.

35:Lerner MJ. The desire for justice and reactions to victims. In: McCauley J,Berkowitz L, eds. Altruism and helping behavior. New York: Academic Press,1970.

36:Ludwig, B. G. (1994). Internationalizing Extension: An exploration of the characteristics evident in a state university Extension system that achieves internationalization. Unpublished doctoral dissertation, The Ohio State University, Columbus.

37:Marx D. Discipline: the role of rule violations. Ground Effects 1997; 2: 1­4.

38:MarxD. Maintenance error causation. Washington, DC: Federal Aviation Authority Office of Aviation Medicine, 1999.

39:Maviglia SM, Yoo JY, Franz C, Featherstone E, Churchill W, Bates DW,GandhiTK, Poon EG. Cost–benefit analysis of a hospital pharmacy bar codesolution. Arch Intern Med 2007; 167: 788–94.

40:Mannila, H. (1997). Methods and problems in data mining. Paper presented at Jiawei, H., & Kamber, M. (2001). Data mining: concepts and techniques.San Francisco, CA, itd: Morgan Kaufmann, 5.

41:Medvedev G. The truth about Chernobyl. New York: Basic Books, 1991.

42:Murry, J. W., & Hammons, J. O. (1995). Delphi: A versatile methodology for conducting qualitative research. The Review of Higher Education, 18(4), 423.

43:Noott A, Phipps GC. Monitoring and preliminary analysis of internal dispensingerrors within a hospital trust. Pharm World Sci 2003; 25: A42–A43.

44:Oswald S, Caldwell R. Dispensing error rate after implementation of a automatedpharmacy carousel system. Am J Health- Syst Pharm 2007;64: 1427–1431.

45:Pawlak, Z., & Sowinski, R. (1994). Rough set approach to multi-attribute decision analysis. European Journal of Operational Research, 72(3), 443-459.

46:Parente, F. J., & Anderson-Parente, J. K. (1987). Delphi inquiry systems. In: Wright, G., & Ayton, P. (Eds.), Judgmentalforecasting, Wiley, Chichester.

47:Perrow,Charles.Normal Accidents. New York :Basic Books; 1984

48:Reason, James T. Human error. Cambridge, MA: Cambridge University Press; 1990 Reason J. Managing the risks of organizational accidents. Aldershot: Ashgate,1997

49:Reason J. Human error. New York: Cambridge University Press, 1990.

50:Reason, J. T., (2008) “The Human Contribution: Unsafe Acts, Accidents and Heroic Recoveries”. Ashgate Publishing, Ltd.

51:Rickrode GA, Williams-Lowe ME, Rippe JL, Theriault RH Jr. Internal reportin system to improve a pharmacy’s medication distribution process. Am J Health Syst Pharm 2007; 64: 1197–202.

52:Rossouw, A., Hacker, M., & de Vries, M. J. (2011). Concepts and contexts in engineering and technology education: An international and interdisciplinary Delphi study. International Journal of Technology and Design Education, 21(4), 409-424.

53:Spencer MG, Smith AP. A multicentre study of dispensing errors in British hospitals. Int J Pharm Pract 1993; 2: 142–146.

54:Teagarden JR, Nagle B, Aubert RE, Wasdyke C, Courtney P, Epstein RS.Dispensing error rate in a highly automated mail-service pharmacy practice. Pharmacotherapy 2005; 25: 1629–35.

55:Thamaraiselvi, G., & Kaliammal, A. (2004). Data mining: concepts and techniques. SRELS Journal of Information Management, 41(4), 339-348. Van den Bemt PMLA, Egberts ACG. Drug related problems: definitions and classification. Eur J Hosp Pharm Pract 2007; 13: 62–4.

56:Walczak, B., & Massart, D. (1999). Rough sets theory. Chemometrics and intelligent laboratory systems, 47(1), 1-16.

57:Weaver, W. T. (1971). The Delphi forecasting method. Phi Delta Kappan, 52 (5), 267-273.

58:Weick KE. Organizational culture as a source of high reliability. Calif Management Rev 1987; 29:112­27.

59:Weick KE, Sutcliffe KM, Obstfeld D. Organizing for high reliability:processes of collective mindfulness. Res Organizational Behav 1999; 21: 23­81.

60:Wetherell, A. (1979). Short-term memory for verbal and graphic information.Proceedings of the Human Factors and Ergonomics Society 23thAnnual Meeting. Santa Monica, CA: Human Factors and Ergonomics Society.

61:Winkler, J., Kuklinski, C. P. J.-W., & Moser, R. (2015). Decision making in emerging markets: The Delphi approach's contribution to coping with uncertainty and equivocality. Journal of Business Research, 68(5), 1118-1126.