導入『創新擴散理論』降低第一年基層護理人員給藥錯誤率

Diffusion of Innovations Theory to Reduce the Medication Administration Error Rate Among Firstyear General Nursing Staff

「提升用藥安全」已連續多年列為醫院醫療品質及病人安全工作目標之一，可見其重要性。統計本院2016年12月至2017年5月給藥錯誤率0.030%，錯誤率倍增且高於同儕醫院，不得不正視及介入改善，以提升病人用藥安全。經探討護理人員給藥錯誤原因，導入創新擴散理論，以設計社群媒體擴散「給藥示範教學」影集及評量、制定「遺漏給藥」病人安全學習教案及線上測試、建置查詢及覆核「未給藥清單」機制、擬定辨識藥物外觀相似度監測模式等策略，來降低第一年基層護理人員給藥錯誤率，結果達設定目標，降低給藥錯誤率至0.018%，達成率120%，期望作為提升護理品質管理之參考。

 

Improving the safety of medication administration has been one of the goals of medical care quality interventions and patient safety initiatives in hospitals for years. The medication administration error rate from December 2016 to May 2017 was 0.030%, which is much higher than that of peer hospitals. This statistic means that the safety of medication administration must be improved. After understanding the reasons behind mismedication, we applied diffusion of innovations theory and designed a campaign involving several relevant strategies for alleviating mismedication. The campaign included medication administration tutorials and their evaluation through social media, a teaching plan focused on patient safety with online tests provided in case of wrong medication administration, and a checking and reviewing mechanism using a medication checklist to learn to identify medications similar in appearance. With this campaign, we hoped to reduce the medication administration error rate of first-year general nursing staff. The campaign was determined to enhance the knowledge of nursing staff. Accordingly, the medication administration error rate decreased to 0.018%, achieving the target rate of 120%. This campaign can serve as reference for other hospitals to improve nursing quality management.