護理人員給藥錯誤之歷程分析

A Study of Nurses' Medication Administration Errors Process Analysis

本研究目的在探討臨床護理人員在給藥過程中發生錯誤的經過及其心理歷程。採質性研究法，以某醫學中心給藥錯誤之護理人員為對象，依半結構式大綱進行深度訪談，歷時8個月，共訪12位護理人員。結果發現：發生給藥錯誤的原因包括對藥物不熟悉、別人幫忙備藥沒有再查核、未依標準流程、依照個人經驗法則執行給藥。給藥錯誤後造成之影響：擔心病人安危、愧對病人及家屬、擔心被懲罰、負面的自我看法、害怕被烙印給藥錯誤之標籤、自我要求按標準程序給藥；藉由剖析給藥錯誤者之歷程，可以辨識給藥錯誤行為之脈絡及早防範錯誤。

The purpose of this study was to investigate the psychological changing process after medication error among clinical nurses by using the qualitative research method. According to the outline of the semi-structured in-depth interviews in eight months, with 12 nurses in a medical center, the results showed that the medication administration errors were due to: nurses admitted unrecognized drugs, not recheck during medication preparation, not follow the standard of medication administration, compliance by personal experience rules. The effects found after the administration error were: fear of position being mobilized, worry about patient safety, guilt towards the patient’s family members, stigma from medication administration errors, self discipline for standard operating procedure. The present study highlights the importance of nurse’s medication administration errors process and prevention.