降低護理師抗癌化學藥物給藥執行錯誤率

Reducing the Error Rate for Chemotherapy Administration by Registered Nurses

化學藥物為具毒性高風險性藥物，一旦發生給藥錯誤，不僅危害病人安全及提高外滲風險，嚴重引發醫療糾紛事件。調查2016年1月至3月單位抗癌化學治療藥物給藥執行錯誤率高達11.84％，化療藥物流速設定錯誤1件（2.94％，1／34x100％），化學藥物治療外滲率0.89％（1／112x100％），化學給藥認知僅84.69％。確認主因為護理師不熟悉化學藥物給藥流程及流速易計算錯誤、化療藥物給藥規範不齊及無稽核機制、無合宜運送設備及定點標示不明；故加強護理師教育訓練及提供運算工具、修訂化學藥物給藥標準作業流程及建立稽核制度、增設化療專用傳送車及定點置放區。改善後護理師化學藥物給藥錯誤率降至4.39％、化學藥物治療給藥認知提升至99.75％及化學藥物治療外滲降至0％。透過專案推展可降低護理師執行化學藥物治療給藥錯誤率，亦可維護病人安全及降低外滲風險。

The process of chemotherapy administration is highly complicated. The chemotherapy medication errors often endanger the safety of patients, increase the risk of extravasation and extend the days in hospital. A survey from January to March 2016 indicates that the error rate of chemotherapy medication administration was 11.84%; there was only one nurse drug flow setting error (2.94%, 1/34x100%); only one patient received the extravasation (0.89%, 1/112x100%); and only 84.69% of the registered nurses (RNs) understood the cognitive behavior of chemotherapy administration. Potential reasons include RNs are not familiar with the procedures of chemotherapy administration and calculation error about the intravenous fluid flow rates. There was no standard operating procedure lack of review system of chemotherapy administration, and no suitable delivery tools. The location of chemotherapy medication was unclear. Therefore, we offered some solutions, including job training, supporting the calculation tools, revising standard operating procedures, building the review system, adding dedicated transport vehicles, and building the specific location for chemotherapy administration. Following these improvements, the error rate of chemotherapy medication administration decreased to 4.39%. 99.75% of the registered nurses (RNs) understood the cognitive behavior of chemotherapy administration, and there was no extravasation. Through the project, we can reduce the error rate of chemotherapy administration, maintain the clinical patient safety and reduce the risk of extravasation.