某醫學中心護理人員給藥錯誤情形之調查

Investigation on Status of Nursing Medication Error from a Medical Center in Southern Taiwan

本研究旨在暸解南部某醫學中心之護理人員給藥錯誤情形。研究樣本為 從92 年8 月至94 年3 月之每月的給藥錯誤異常通報事件（共186 件） ，結果顯示 有144 名護理人員於病人住院期間的給藥錯誤發生率為0.027% （範園介於 0.011-0.059% ）。給藥錯誤以針劑（65.3% ）佔最多。錯誤類型方面則以藥物 （39.3% ）、劑量（35.7%） 、病人（9.7%） 為多；白班發生的比例高 （44.6%） ；護理人員重複發生錯誤者佔19.5% ；經評估後，病人未造成傷害只 需觀察。專科與大學學歷者在錯誤的件數上無明顯差異，但在進階層級與工 作年資方面，均明顯呈現新進及一年內的護理人員最容易發生錯誤。原因多 源自於備藥及給藥時未確實執行「三請五對」標準流程或對藥物的認識不 足。在分析過程亦得知護理人員對給藥錯誤的認知有欠缺。因此，未來宜加 強護理人員（尤其針對新進人員）封給藥錯誤的認知，給藥安全的教育訓 練，並擬定具體可行之介入性護理措施，且管理者需要有效改善用藥系統， 才能降低給藥錯誤發生率，確保病人用藥之安全。

This study was aimed to understand the medication error in a Medical Center in southern Taiwan. The sampling cases were collected from the monthly medication error incident reports from August 2003 to March 2005 (186 cases in total). The analysis showed that the medication error rate generated in hospitalization by 144 nurses was 0.027%. The injection drugs accounting for 65.3% dominated the medication error. Among the major types were drug (39.3%), dosage (35.7%) and patients (9.7%). In terms of shift, the day shift was 44.6%, the highest. The nurses who committed repeated error were 19.5%. After assessing, the patients affected by the incidents were not injured and only needed observation. There was no significant discrepancy in the nurses' academic level. However, in the clinical ladder and working tenure, it was shown that the newly recruited and freshman (less-than-oneyear work experience) nurses were most likely to commit errors. The errors were mainly because of not thoroughly conducting three-reading- five-right drug preparation and administration standard procedures, lacking of drug knowledge, or short of the perception. Therefore, it is needed to enhance the nurses', especially the new nurses, training about drug safety, and draft the feasible intervening nursing measures. The managers also need to advance the drug system to effectively reduce the medication error rate and assure the patient with drug safety.