高警訊藥物安全作業改善專案經驗

Project of Improvement of High alert Medicine Usage

加護病房中，因疾病嚴重度偏高，高警訊藥物使用頻繁，單位若無完善之管理機制及護理人員正確的用藥知識，易造成給藥的錯誤。故本專案針對高警訊藥物使用作業進行改善，期盼能防範用藥疏失之發生，提升用藥安全。經由本專案資料分析結果發現：(1)護理人員對高警訊藥物使用認知應加強(2)單位高警訊藥物用藥作業流程及儲存辦法不明確(3)單位高警訊藥物用藥安全無稽核辦法。依據問題分析、擬定改善措施為：1.製作高警訊藥物手冊2.舉辦在職教育3.建立雙重稽核機制4.製作藥物資訊公佈欄5.高警訊藥物警示標籤6.制定藥物認知題庫定期稽核。經由此專案：護理人員對高警訊藥物認知測試由平均63.5提升至90分，制定高警訊藥物使用流程與稽核辦法，有效管理高警訊藥物，維護病人用藥安全提升照護品質。

Within Intensive Care Unit there is a high level usage of high alert medicine due to the severity of illness. Incomplete medicine management, and medical carer insufficient professional knowledge usually leads to clinical errors. This project is intended to improve high alert medicine usage, prevent clinical errors, and enhance medicine usage safety. There are three main outcomes discovered in this project. 1) medical carer ought to have better knowledge of how to use high alert medicine. 2) ICU needs to have clear procedural process of how to use and preserve high alert medicine. 3) ICU has no specific checklist of high alert medicine. According to this analysis there should be measures to improve high alert medicine usage: making of high alert medicine blue book; on the job training; double check process; medicine product information board; security tag of high alert medicine; and medicine regulation checklist. After this project, medical carer improve their knowledge and scored 26.5 points higher. ( 63.5 to 90) A new well developed procedure and complete checklist to high alert medicine has been established. Efficient management of high alert medicine also has been developed, and patients are provided with better quality medical care in using high alert medicine.