心臟血管病房護理人員執行靜脈藥物劑量計算之改善方案

The Improvement of Intravenous Drug Dosage Calculation among Nurses in Cardiology Department

護理人員在執行靜脈注射藥物中，若發生劑量計算失誤，嚴重者影響病人的病情及生命。本單位曾發生給藥錯誤共2 次，經測試護理人員在靜脈藥物劑量計算錯誤率為43%，故引發專案改善動機。依現況分析發現，護理人員缺乏劑量計算相關訓練課程，在劑量計算過程複雜且耗時，且易受人事干擾中斷，提供公式計算參考單滿意度低所致。本專案目的為降低靜脈藥物劑量計算錯誤率，縮短劑量計算時間，提升劑量計算工具滿意度。解決方案包括安排在職教育訓練；發展藥物劑量計算資訊輔助系統；制定靜脈藥物計算劑量( 體重或一般) 回推覆核機制；建立藥物劑量計算資訊輔助系統操作指引說明；建立防止劑量計算受干擾之機制；建制電腦當機劑量計算覆核驗算機制。經實施以上方案後，結果為：藥物劑量計算錯誤率由43% 降為0%；劑量計算時間由6-10 分鐘縮短為30-40 秒；公式計算參考單滿意度由2.37 分，經藥物劑量計算資訊輔助系統介入後提升4.76 分。結論：藥物劑量計算資訊輔助系統可縮短劑量計算時間，改善藥物劑量計算錯誤，提升護理人員滿意度，現已推廣至他科，以確保病人用藥安全。

Dosage calculation errors by nurses during administration can potentially be life threatening and cause great harm to patients. Medication errors occurred twice at the unit. An error rate of 43% in calculating intravenous medication by nurse was identified. The project was therefore initiated to improve the accuracy. The results of the analysis indicated that the error was largely due to lack of adequate training program on drug dosage calculation, the calculation process is too complex and time-consuming, frequent interruption by others, and low satisfaction with the calculation tool. The aim of this project was to reduce error in calculating drug dosage, decrease calculation time, and increase the satisfaction toward drug calculation tools. The improvement strategy included providing on-job training, building a Drug-Dosage Decision Supporting System and its operation guideline, providing a framework to avoid interference during drug dosage calculation, and establishing a double-checking system for dosage calculation in case of computer system failure. The results showed that the drug dosage calculation error rate reduced from 43% to 0%. The calculation time decreased from 6-10 minutes to 30-40 seconds. After the implementation of computer assisted program for dosage calculation, the satisfaction rate improved from 2.37 to 4.76. In conclusion, assisted system for dosage calculation could shorten calculation time and improve satisfaction among nursing staff. As a result, this system has also been implemented in other departments to ensure medication safety for patients.