病人藥物血中濃度監測之風險分析與改善方案

Patient Serum Drug Concentration: Monitoring, Risk Analysis and Proposed Improvements

在1998年美國醫學會期刊報導發現，因為住院病人藥物使用不當，引起致命性的藥物不良反應就有0.32％，其中原因有藥物血中濃度監測疏失，而國內學者研究也提到藥物劑量監測不當，易造成病人副作用增加，甚至危及生命。在臨床照護中看到護理人員未依指定時間執行藥物血中濃度抽血，使得藥物血中濃度監測的正確性打了大問號，也引發病人用藥安全之思慮，有感其重要性，本專案運用健康失效模式及效應分析，對藥物血中濃度監測流程做風險評估，並以自擬結構式問卷為調查工具，藉實地觀察及問卷調查，發現護理人員對藥物血中濃度監測的原因，及監控時間的重要性不瞭解，因此針對錯誤率高的四個單位，研擬解決方案，並透過教育訓練、藥物血中濃度監測提示標語、藥物血中濃度監測查核表、設立藥物血中濃度監測諮詢專線，結果護理人員藥物血中濃度監測知識正確性從6.53分提升為8.65分，執行錯誤率從18.46％降低為0，故印證教育與持續監控，可提昇藥物血中濃度監測執行的正確性。從此次專案期望將來納入護理常規在職教育中，對於病人安全及臨床護理實務將有莫大助益。

In 1998, a study published in the Journal of the American Medical Association reported that inappropriate drug concentration could lead to fatal adverse drug reaction. About 0.32% of hospitalized patients were administered with fatal drug concentrations. Studies in Taiwan also supported this observation, suggesting the importance of serum drug concentration monitoring. A survey was conducted at a single tertiary medical center. It utilizes the health care failure mode and effect analysis to assess the existing serum drug concentration monitoring protocol and risk assessment in the nursing staff. Preliminary survey noted that the majority of the nursing staff were not familiar with drug concentration issues and lack of proper sampling techniques. In order to improve such problems, courses, educational seminars, reminder notes, tables and telephone hotlines were provided. Follow up survey analysis showed that overall knowledge improved from 6.53 to 8.65. Inaccurate monitoring and sampling techniques decreased from 18.5 % to zero. This article suggested further nursing staff education and persistent monitoring is needed to further improve the quality of patient care.