提昇護理人員口服給藥正確性之改善專案

A Project to Increase the Accuracy of Oral Medication Administration for Nurses

口服給藥是護理人員每日必需執行的護理活動之一，如果發生給藥錯誤，不僅會直接影響病人安全，嚴重時可能會導致病人死亡，故本專案旨在提昇護理人員口服給藥之正確性，以減少因給藥錯誤而導致潛在的不良結果。經現況分析後，發現護理人員對口服藥認識正確率只有49%，而口服給藥執行正確率僅為45%。經製作單位內常用藥物手冊、口服藥實體標本、訂定口服給藥標準作業流程及實施在職教育等措施後，護理人員對口服藥物的認識正確率提昇99%，給藥流程執行正確率達100%，雖正確率均有大幅提升，但仍未完全達到本專案目的，所以繼續努力是需要的。本專案之實施，不僅提升臨床給藥正確性，且可維護病人用藥之安全。Oral medication administration is one of the daily tasks for nurses. As a result, if a medication error occurred, it would not only directly affect patient safety, but also could cause patient death. Therefore, the aim of this project was to improve the accuracy of oral medication administration and to reduce adverse effects caused by medication errors. Data analysis were shown that the accuracy of medication identification was only 49% and 45% for medication administration by nurses. After producing a unit medication manual, medication symbols, setting medication standard procedures, and holding continuing nursing education, the accuracy of medication identification and medication administration by nurses increased to 99% and 100%, respectively. Although the overall rate of medication accuracy was increased, the aim was only partially achieved. Therefore, improvement is still needed. Nonetheless, the implementation of this project not only increases the medication accuracy, but also maintains patient safety.