護理人員高警訊藥物給藥過程缺失率改善專案

A Project to Improve Nurses’ Error rate when Dispensing High-Alert Medications

給藥錯誤不僅會造成病人面臨死亡威脅和健康危害，甚至引發醫療爭議。本單位於2014年6月發生一件屬高警訊藥物之胰島素輸液幫浦給藥錯誤事件，其劑量被錯誤調整成原劑量10倍，進而著手根本原因分析調查，此事件引發專案小組深入探討單位高警訊藥物給藥過程缺失之動機，故於2014年7月9日至7月16日以查檢表對單位護理師進行高警訊藥物給藥過程查核，發現缺失率高達42.85%，本專案旨在降低高警訊藥物給藥過程缺失率。方法由現況分析發現錯誤原因包括：一、缺乏教育訓練。二、高警訊藥物使用作業標準流程定義不明確。三、缺乏教學演練、回覆示教及常規查檢監測。經文獻查證及距陣分析選定改善策略包含：（一）與醫師溝通處方規範、（二）修訂高警訊藥物使用作業標準、（三）拍攝口頭醫囑及高警訊藥物執行流程影片、（四）舉辦用藥安全教育訓練、（五）舉辦教學雙向演練並實地查核建立制度。

Purposes Dispensing errors not only heighten patient’s risk of death and cause damage to theirhealth, but can also cause medical disputes. An incident of dispensing error involving ahigh-alert medication occurred in our hospital on June 2014, where the dose of insulininfusion pump administered was 10 times more than the original dose. We carried outan investigation and analysis on the root causes of this incident, which led our group tofurther investigate the reasons for dispensing errors in high-alert medications. Hence,from July 9 to 16, 2014, we carried out an inspection on the dispensing procedure of highalertmedications by nurses using a checklist. We found that the dispensing error ratewas up to 42.85%, and this project aimed to reduce the dispensing error rate of high-alertmedications.MethodsAn analysis of the current situation found that causes of dispensing errors included: 1.lack of education and training; 2. unclear standard operating procedures on the use of highalertmedications; and 3. lack of teaching exercises, repeated demonstrations, and routineinspection and monitoring. After literature verification and matrix analysis, we proposed thefollowing improvement strategies. (1) communication with the physician on prescriptionspecifications. (2) revision of the standard operating procedures for the use of high-alertmedications. (3) filming videos for verbal medical instructions and standard operatingprocedures for high-alert medications. (4) conducting safety education and training on theuse of medications. (5) conducting two-way teaching exercises and on-site inspection of theestablished system.ResultsSince the implementation of these improvement strategies, an efficacy evaluation fromOctober 6 to 20, 2014 found that dispensing errors decreased from 42.85% to 0.00%. Followupinspection until December 2016 found no incidences of dispensing errors for high-alertmedications.ConclusionsThis project implemented various effective measures, such as repeating andpromoting prescription specification to achieve a consensus between nurses and physicians,promotion of revised standards in various nursing units, use of education and training toimprove the awareness and attention of colleagues, and continuous quality control. Thisenabled the problem to be solved, thus safeguarding the safety of patients and improvingthe quality of dispensing medications.