英文摘要 |
The intravenous drug dosage error resulting in unstable vital signs in one child was found in ourPICU (Pediatric Intensive Care Unit). We analyzed data from the intravenous medication checklistand found that the rate of incorrect intravenous administration was 3.7%. After conducting interviewsand summarizing the interview results, we concluded the following causes: the nurses possessedinadequate ability to determine the correct medicine dose; standards for storing leftover medicine werenot established; leftover medicines were improperly labeled, doses were not double-checked by anothernurse; the time pressure of keeping dosage records leading to mistakes occurring easily; and the nursesdiluted drugs and stored leftover medicine according to their experience only. The aim of this project wasto decrease incorrect intravenous administration to 0%. Strategies of this project included completinga user guide for common drugs, providing nurse’s continuous educational program on intravenouslyadministering drugs, designing stickers for labeling leftover medicine, adding medicine doses on themedicine administration record, establishing computerized order management system for automaticallycalculating the appropriate medicine dose, and developing double-checking procedure for intravenousadministration. After this project, incorrect intravenous administration rate decreased to 0% and noadverse medication event occurred in nearly one and half year. The result indicated the intervention of thisproject can increase accuracy of intravenous drug infusion and effectively maintain drug safety for childinpatients. |