給藥錯誤事件綜論──急診室、加護中心、兒科病房

Medication Errors in Emergency Rooms, Intensive Care Units and Pediatric Wards

病人用藥安全，是一個關係到病患照護品質與照護安全上的重要考量與全球性的議題，而其中最重要的目的是減少給藥錯誤的發生。本文藉由文獻查證，共歸納出三個容易給藥錯誤及導致病患傷害的單位；分別是急診室、加護中心、兒科病房。在急診室由於時間緊迫，缺乏病患的詳細病史，再加上多使用急救藥物，使得給藥錯誤率較一般病房高。在加護中心，由於病患處於低反應情境，加上用藥複雜且多使用高危險藥物，也使得加護中心的給藥錯誤率偏高。在兒科病房，由於劑量需按照小兒體重計算，然而部份護理人員因計算能力不佳而導致給藥錯誤。本文綜合整理上述三個單位的給藥錯誤文獻，提供護理人員參考，期待能增加護理人員對給藥錯誤此一議題的認知，並能落實執行給藥的標準作業程序。

Medication safety is a major concern worldwide that directly relates to patient care quality and safety. Reducing medication error incidents is a critical medication safety issue. This literature review article summarizes medication error issues related specifically to three hospital units, namely emergency rooms (ERs), intensive care units (ICUs), and pediatric wards. Time constrains, lack of patient history details and the frequent need to use rapid response life-saving medications are key factors behind high ER medication error rates. Patient hypo-responsiveness, complex medication administration and frequent need to use high-alert medications are key factors behind high ICU medication error rates. Medication errors in pediatric wards are often linked to errors made by nurses in calculating dosage based on patient body weight. This article summarizes the major types of medication errors reported by these three units in order to increase nurse awareness of medication errors and further encourage nurses to apply proper standard operational procedures to medication administration.