提升護理人員執行化療給藥步驟之正確性－－不良事件根本原因分析之應用

Promoting the Accuracy of Chemotherapy Medication Administration for Nurses: An Application of Root Cause Analysis

給藥錯誤一直是醫療院所普遍存在的問題，其發生大多起因於護理人員未依標準步驟執行給藥，本文旨在描述中部某區域教學醫院於2008年1月發生一起化療給藥錯誤之不良事件後，護理品質小組運用根本原因分析法，改善不良事件、提升婦產科病房護理人員執行化學治療給藥步驟正確性之專案改善過程。小組於2008年2月24日至26日針對全體護理人員進行化療給藥步驟之稽核，發現所有人員均未通過查核。經分析發現護理人員執行化療給藥步驟不正確之根本原因屬於系統層面之問題，包括：醫囑開立不清晰、缺乏醫護作業標準、缺乏相關教育、資訊設計不完善。故根據文獻資料及矩陣分析決定改善策略，包括：統一醫囑形式、系統建立及標準化、舉辦教育訓練及資訊系統更新。策略實施後化療給藥步驟之正確率可提升至100%，本專案之改善經驗可作為臨床第一線管理者進行不良事件分析改善之參考。

Drug administration error in the hospital ward is an ever-present problem and an all-too-frequent occurrence. Such errors are often made by nurses who fail to follow relevant nursing standards. The aim of this article was to describe an adverse event of chemotherapy-related medication error that happened in an academic hospital located in central Taiwan. The authors and their colleagues used root cause analysis to survey the adverse event and to suggest ways to improve the accuracy of nurse chemotherapy medication administration. We investigated medication administration of chemotherapy made by nurses between February 24th and 26th, 2008, and found that a number of nurses failed to administer medication properly. Based on data analysis, root causes were identified as: (1) directed prescriptions were unclear, (2) chemotherapy medication administration lacked protocol guidance, (3) education was insufficient and (4) computer systems were inadequately designed. Based on a literature review and matrix analysis, the task force identified four major categories in which improvements were needed. These included: (1) prescription promotion, (2) protocol development and standardization, (3) education for healthcare practitioners and (4) improvement of computer systems. After improvements were put into practices, the accuracy of chemotherapy medication administration by nurses increased to 100%. We shared the promotion experience with clinical managers to analyze and avoid adverse events.