應用根本原因分析於提升嬰兒連續性靜脈給藥安全之改善專案

Applying Root Cause Analysis to Promote the Medication Safety of Continuous Drug Infusions for Infants

背景：2010年嬰兒加護單位因連續性靜脈給藥劑量錯誤，導致嬰兒傷害事件。經品管小組運用根本原因分析法，歸納出藥物不良事件之原因，包括：醫師處方開立程序不正確及內容不完整、護理師執行連續性靜脈給藥步驟不完整、確認醫囑的流程複雜、手抄醫囑於治療單不僅耗時且易抄錯、護理師專業認知不足等組織系統方面的缺失。目的：期能達成護理師執行連續性靜脈給藥步驟完整率為100%，給藥異常事件為0件。解決方案：改善策略包含：簡化確認醫囑流程、制定醫師處方規範、制定標準化連續性靜脈給藥步驟、規範連續性靜脈給藥劑量之配製藥量，與建制高警訊藥物雙人核對機制。除循序建立上述之改善措施外，同時提供單位護理師相關教育訓練，以落實方案執行。結果：經計畫至執行後，評值改善策略之成效，發現給藥步驟完整率提升至99%，醫師處方開立正確率提升為96%；評值期間無藥物不良事件發生。結論：本專案建立之系統性安全給藥機制，可增進醫護照護團隊間溝通與合作，進而提升嬰兒給藥安全及品質。

Background & Problems: An adverse medication event involving a continuous drug infusion dosage error was reported in the infant intensive care unit of our hospital in 2010. The causes of this adverse medication event were elicited in the healthcare network using root cause analysis. These causes included incomplete procedures and incorrect prescription, an incomplete procedure of medication in continuous drug infusion, complex procedures in confirming prescription, the transcription of doctor's orders and prescription (i.e., kardex), and deficient knowledge of medication procedures exhibited by clinical nurses.Purposes: The main purpose of this project was to achieve a 100% completion rate for nurse administrations of continuous intravenous medication and zero adverse medication events.Resolutions: Strategies included simplifying the prescription verification process, establishing regulations for drug prescription, standardizing the steps required for continuous intravenous medication administration, developing the dosage criteria for continuous intravenous medication, and developing a double-check mechanism for high-risk medications. In addition, relevant nurse's continuous educational programs were provided to help nurses effectively implement drug administration.Results: The completion rate for administering the medication steps has increased to 99% and the compliance rate for pediatricians' orders regarding medication prescription has increased to 96%. Furthermore, no additional adverse medication events were observed after the intervention.Conclusion: This project established a systemic drug administration mechanism to promote communication and cooperation among healthcare teams and further enhanced medication safety and quality for infants.