To err is human, Everyone makes mistakes, including doctors and nurses. According to studies cited in the Institute of Medicine report, 98,000 Americans die each year as a result of medical errors. This statistic is associated with a cost of US$17 to US$29 billion and ranks medical error the eighth leading cause of death in the United States. Medication errors account for approximately 7.000 deaths per year. Medication errors are any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and dispensing; distribution; administration; education; nomenclature; compounding; monitoring; and use. To err is human, but errors can be prevented, Improving system defect is a more effective way to reduce errors than blaming individuals. Health care is a decade or more behind other high-risk industries in its attention to ensuring basic safety. Aviation has focused extensively on building safe systems. To improve safety is first to create an environment that encourages individuals to identify errors, evaluate causes and take actions to improve performance in the future. Non-punishment reporting systems represent one mechanism to enhance our understanding of errors and the underlying factors that contribute to them, A number of error prevention tools are helpful to improve safety. Studies have shown that Computerized Physician Order Entry and Bar-code system are effective in reducing medication errors. Also, pharmacists can play an important role in medication safety by educating the patients to take the drugs properly. Drug companies should pay attention to drug names and drug-looking to minimize confusion between drugs that look or sound alike. If we want to improve our healthcare system in Macau, we need to be open to discuss the topics about errors. Also, a legal system should be established. HIS should be introduced to help doctors. pharmacists and nurses to reduce errors Keywords: medication errors, system defect, non-punishment reporting systems

To Err Is Human 人誰無錯，因此，即使是醫療機構内的每一個人都不例外。但是，一旦發生了藥物差錯，便可能會導致病人的傷害，重者甚至死亡。用藥疏失(medication error)，是指從醫生處方，醫囑傳譯，藥房配藥，藥物標籤包装，藥物分發，護士執行，藥物使用監测，以至到藥物使用的過程中，存在有可预防性的錯誤。據美國醫學研究院於1999年底作過估計，認為單是美國每年死於醫療差錯約有98,000人，為第八大死因，遠超過交通事故的死亡人数(43,458)及乳癌死亡人数(42,297)，或者AIDS死亡人数(16,516)。而其中用藥疏失導致的死亡人数估計有 7,000人，高於工業死亡人数的6,000人。計算，每131個門診病人便會有一個死於用藥疏失，每854個住院病人便會有一個死於用藥疏失。這些錯误引致經济损失的费用，包括收入损失，生產力损失及醫療费用花费，估計有170億至290億美元。其中醫療费用估總花费的一半以上。疏失的產生往往是出於醫療體系的缺失，若對犯錯的個人定罪或苛责，則仍是無法避免同樣的疏失再度發生。所有系统均有潜在性失誤的風險，但内建的防護措施往往不夠，只要有一連串的疏失，很容易便會引起災難。其他高風險的工業，如航運業與核能工業等，對失誤的思考與研究已經逐渐轉型，並已重新設計系统以大幅地降低人為疏失。醫療體系對防範疏失發生的關注力遠遠落後於其他高風險工業超遇十年以上。 要研究醫療系统潛在的缺失，防止差錯的發生，首先便是要建立安全文化，醫療人员要敞開心胸，積極参與，仿照航運業，採用非懲罰性通報系统，收集分析問题，再加以改善。國家亦應設立全國通報機制，整合及分享资訊。同时，我嗎們亦要正视人類的極限，設立輔助機制，包括制定程序表、使用電腦化醫生醫嘱输入系统(CPOE)、利用 Bar-Code system 等等,可大大減低差錯率。同時，藥師亦可扮演一個重要角色，對病人用藥作出適常指導,提高用藥安全。藥廠在設計藥物的包装,以及命名的時候，亦應花一些心思，以减少因外觀相似、讀音相似而造成的混淆。 要改善澳門的醫療系统，首先要改變我們舊有的觀念，及應完善法律體制。另外，建立 HIS系统亦可有助改善差錯。 開鍵詞:用藥疏失 系統缺失 非懲罰性通報系统