目標：病人安全是全球公共衛生重要的議題之一，中央健康保險署嘗試對重複用藥高風險族群寄發關懷函提醒。本研究以質性方法分析民眾在收到關懷函後來電回應的內容，以瞭解病人認知與解釋重複用藥之相關因素。方法：本研究團隊與健保署合作，根據健保署所提供2019年1月至3月間確認的重複用藥核扣名單，針對20歲以上且有使用降血糖或降血脂兩類藥品使用者為研究個案，寄發重複用藥提醒關懷函，於2019年7月1日至7月7日，共郵寄出11,000份關懷函，至8月13日止，陸續接獲265通民眾的回應電話，本研究係以民眾回應之內容進行主題分析。結果：根據民眾的電話回應，歸納與整理出以下的六大主題，分別為：民眾對於重複用藥的認知、民眾端認為與解釋重複用藥之個人因素、醫師因素、醫病關係，非醫療情境因素與其他回應等等。結論：重複用藥是一個複雜的問題，其發生存在不同面向的原因，需要病人與醫事人員的共同努力，方可保障病人用藥的安全。

Objectives: Patient safety is a major issue in global public health. The National Health Insurance Administration (NHIA) in Taiwan introduced a pilot mail-reminder project for patients with duplicated medication. The responses of those who received the reminder letter were qualitatively analyzed to elucidate how they understand and explain the medication duplication. Methods: The research team collaborated with the NHIA and obtained a list of patients with duplicated medication; patients who were aged over 20 years and who received medication for hyperlipidemia and hyperglycemia were selected for this study. A total of 11,000 reminder letters were mailed to the selected patients during July 1–7, 2019. Until August 13, 2019, a total of 265 phone calls were received from the patients. The patients’ responses were analyzed using thematic analysis. Results: Six themes were identified: patient knowledge on medication duplication, patient-perceived individual factors related to medication duplication, patient-perceived doctor factors related to medication duplication, the relationship between health professionals and patients, nonmedical context influencing medication duplication, and other responses. Conclusions: Medication duplication is a complicated matter and exists for various reasons. Thus, a concerted effort is required by patients and health professionals to address this problem and enhance patient medication safety.