運用多元策略降低門診護理師特殊藥品給藥錯誤

給藥錯誤危及病人健康及增加醫療成本。本單位為醫學中心內科門診治療室，2022年1~6月特殊藥品給藥異常增至3件，已高於2021年1件，故引發專案動機。針對特殊藥品給藥異常，制定有效的解決方案，提高護理師對特殊藥品的認知及技能，從而降低異常事件。通過分析問題，確認護理師執行特殊藥品給藥之操作與認知正確率低且流程及制度不完善。因此，制定標準流程、舉辦教育訓練、製作藥品展示牆、運用電子資訊註記功能，並結合QR code傳遞訊息。在專案執行的8個月後，未發生給藥異常，已達專案目標，且特殊藥品給藥之操作與認知正確率，分別由59.6%及60%提升至100%。有鑒於此專案良好的結果，建議未來推廣至門診其他治療室，以確保病人用藥安全。

Medication errors endanger patient health and increased costs. In the outpatient treatment room of the internal medicine department at a medical center, we observed an increase in medication errors involving special medications from January to June 2022. The number of cases rose to 3, compared to 1 case in 2021, prompting the initiation of this project. The objective of this study was to devise effective solutions for the administration of special medications, aiming to enhance nurses’awareness of these medications and their proficiency in correct operation, consequently minimizing the incidence of irregular occurrences. Through problem analysis, we identified a low level of accuracy in both the skills and knowledge required for administering special medications, along with a disorganized process and system, leading to an increase in medication errors. Therefore, we established standard operating procedures for administering special medications, conducted educational sessions, made medication posters, utilized an electronic medical reminder prompt, and incorporated a QR code for information delivery. Eight months post-project implementation, no errors were identified in special medication administration, meeting our project goal. Accuracy rates for the skills and knowledge needed to administer special medications rose from 59.6% and 60% to 100%, respectively. Given our favorable results, we recommend extending the project to other outpatient treatment rooms to ensure medication safety and enhance the quality of care.