降低外科加護病房護理師執行條碼給藥錯誤發生率之改善專案

Reduce the incidence of error the implementation of Bar Code Medication administration in Surgical Intensive Care Unit nurse

目的：2015年外科加護病房給藥錯誤事件共14件，發生率為0.16%，高居全院加護病房給藥錯誤通報事件之冠，因此成立專案小組，期望降低外科加護病房給藥錯誤發生率。方法：本專案自2016年4月至2017年7月，透過柏拉圖及魚骨圖分析確立條碼給藥錯誤主要因並進行對策措施，包括1.設立查核機制、2.製作條碼給藥步驟流程圖、3.製作給藥警示標語牌、4.設置給藥提醒鈴聲、5.調整條碼系統畫面劑量的設定。結果：（一）專案宣導會議出席率高達91%，且獲同仁一致認同。（二）監測給藥被中斷後重新核對藥物的動作，此習慣由0%提升至100%。（三）護理師備藥中被干擾比例從46%下降至0%。（四）條碼給藥畫面「數量」字體變大之調整，滿意度從75%提升至100%。（五）“提醒給藥鈴聲＂之設計，遺漏給藥之比率從54%降至0%。給藥錯誤率下降至0.08%，達專案之目標。結論：透過此專案實施過程不但獲得同仁正向的回饋，亦凝聚單位同仁品管改善之精神，然給藥異常事件仍應該持續被重視及對策改善，期待持續藉由臨床持續監測之實施，落實病安文化之把關！ Objective: In 2015 SICU dosing errors were 14 events, the incidence of 0.16%, and the highest incidence of false notification was in the intensive care unit of the whole hospital. Therefore, set up a Project to reduce the incidence of error the implementation of Bar Code Medication administration. Methods: The project from April 2016 to July 2017, through the analysis of Plato and fishbone chart to determine the main reasons for Bar Code Medication administration errors and Strategies, Include: (1) To establish a Check mechanism, (2) Make the Barcode delivery steps flow chart, (3) Make a warning placard, (4) Set medication reminder ringtones, (5) Adjust the bar code system screen dose settings. Results: 1. Project Advocacy Conference attendance as high as 91%, and agreed by colleagues. 2. Monitoring the Medication administration was interrupted after the re-check the movement of drugs, this habit from 0% to 100%. 3. nurses prepared medicine was disturbed from 46% to 0%. 4. Adjustment of the font size of the barcode dosing screen becomes larger, and satisfaction is raised from 75% to 100%. 5. The design of ＂Reminders for Ringtones＂ dropped the percentage of missed medicines from 54% to 0%. Medication administration error rate dropped to 0.08%, go to the project's goal. Conclusion: Through the implementation of this project, not only the positive feedback from colleagues, but also the spirit of improvement of quality control, the abnormal event of drug administration should continue to be taken seriously and the countermeasures should be improved. We are looking forward to continuing to ensure the safety of patients through continuous clinical monitoring Cultural!

Objective: In 2015 SICU dosing errors were 14 events, the incidence of 0.16%, and the highest incidence of false notification was in the intensive care unit of the whole hospital. Therefore, set up a Project to reduce the incidence of error the implementation of Bar Code Medication administration. Methods: The project from April 2016 to July 2017, through the analysis of Plato and fishbone chart to determine the main reasons for Bar Code Medication administration errors and Strategies, Include: (1) To establish a Check mechanism, (2) Make the Barcode delivery steps flow chart, (3) Make a warning placard, (4) Set medication reminder ringtones, (5) Adjust the bar code system screen dose settings. Results: 1. Project Advocacy Conference attendance as high as 91%, and agreed by colleagues. 2. Monitoring the Medication administration was interrupted after the re-check the movement of drugs, this habit from 0% to 100%. 3. nurses prepared medicine was disturbed from 46% to 0%. 4. Adjustment of the font size of the barcode dosing screen becomes larger, and satisfaction is raised from 75% to 100%. 5. The design of ＂Reminders for Ringtones＂ dropped the percentage of missed medicines from 54% to 0%. Medication administration error rate dropped to 0.08%, go to the project's goal. Conclusion: Through the implementation of this project, not only the positive feedback from colleagues, but also the spirit of improvement of quality control, the abnormal event of drug administration should continue to be taken seriously and the countermeasures should be improved. We are looking forward to continuing to ensure the safety of patients through continuous clinical monitoring Cultural!