以跨團隊管理及資訊輔助降低給藥錯誤事件

Reduce the Risk of Medication Administration Errors: A Disciplinary Team Management and Information System Support

給藥過程發生錯誤事件一直是重要病人安全影響課題，但在條碼科技輔助給藥標準下，2019年外科組護理人員仍通報九件藥物事件出現改善瓶頸，故團隊以事件通報資料和現場調查分析，確認問題為：全院跨團隊問題之住院病人之院外自備藥，及護理站管制藥取用資訊系統薄弱，及外科病房護理人員給藥未遵守「兩刷條碼和五對」及給藥被中斷後造成錯誤；透過雲端藥歷連動住院處方和給藥護理資訊系統，及智能管制藥櫃系統設置，推動護理師給藥過程完整率和降低給藥被中斷措施後，病人給藥被中斷由改善前4,700人次降至改善後2,123人次，且2020年4月執行專案後，到2021年10月評價期中，僅一件未使用雲端藥歷下載事件通報，顯示以跨團隊專案介入和資訊輔助可改善錯誤，增加病人安全。

Medication errors that occur during drug administration can be attributed to various safety factors. Although barcode technology–assisted medication administration had been implemented in a hospital in Taiwan, a team of surgical nursing staff reported 9 adverse drug events in 2019, for which investigations were conducted on-site. An analysis revealed several problems, including a weak information system for the self-prepared inpatient medication and drug operating system operated by a surgical ward, which affected cross-disciplinary teams across the entire hospital. Furthermore, the nursing staff of the surgical ward did not comply with the“two barcode checks and five rights”guideline for medication administration, resulting in errors due to interruptions during medication administration. Through the integration of hospital systems (i.e., a prescription system, a medication administration information system, and the Pharma Cloud System), the establishment of an automated dispensing cabinet system, the improvement of the medication administration completion rate, and the reduction of medication administration interruptions, the number of interrupted patient doses was reduced from 4,700 to 2,123. Only one adverse medication administration event was reported between April 1, 2020, and October 31, 2021, indicating that the implementation of the cross-disciplinary project and information assistance system reduced medication errors and increased patient safety.