降低病人操作胰島素筆型注射器錯誤率方案

A Project to Reduce the Rate of Operational Mistakes in Using Insulin Pen Injection Device among Diabetic Patients

本專案旨在使病人操作胰島素筆型注射器錯誤率由43.3%降至15.9%以下。組員於2004年8月調查發現，出院前評值病人胰島素筆型注射器操作錯誤率為43.3%，經分析發現原因有：衛教工具不足、未定期監測衛教成效、護理人員技術不熟練且認知不一致及未建立標準作業流程等四項問題，導致病人錯誤率偏高。故成立專案小組，擬定四項解決辦法：制訂胰島素筆型注射器衛教單張、標準盤及衛教光碟;成立稽核小組;安排胰島素筆型注射器操作知識、技術及衛教技巧之在職教育;訂定胰島素筆型注射器衛教標準流程。經措施執行後，病人操作筆型注射器錯誤率降至10%，達到設定之目標。顯現本專案具改善成效，期望此專案能持續施行及監測，確保病人得到更好的護理指導品質。

This project has fulfilled the purpose of reducing the rate of operational mistakes committed bypatients while using insulin pen injection device from 43.3% to 15.9%. Through the investigationconducted inAugust 2004, team member disclosed that the rate of operational mistakes committedby patients in using insulin pen injection device before discharge was 43.3%. The analysis demonstratedfour predisposing factors as follows: inadequate teaching tools for health education, lack ofmonitoring the efficacy of health education on a regular basis, poor proficiency in the technique andcognitive deficiency of the nursing personnel, and the absence of establishment of the standardoperational procedures, respectively.All these four problems led to the high rate of mistakes amongthe patients. A special team was established and the proposal of resolutions for the problems waslaid as follows: production of health education leaflets for the operation of insulin pen injectiondevice, standard tray and floppy disc, founding of an audit team, organization of on-job education toteach skills of health education, technique and operational knowledge for using insulin pen injectiondevice, and setting up of algorithm for the health education for using insulin pen injection device.Upon implementation of these measures, it was found that the rate of operational mistakes committedby patients when using insulin pen injection device dropped to 10%; thereby achieving theestablished goal. It indicates that this project contributes to effective improvement.We expect thisproject to be carried out continuously to monitor and ensure better quality of nursing instruction forthe patients.