轉床病人給藥之改善方案

The case report on medicine shift procedure in patients of transfer beds Dishes

病人安全目標中包括用藥安全，足見用藥安全爲不可疏失一環。本院病人轉床發現延遲給藥及護理人員耗時追藥的問題，經查核統計自92年7月1日至7月31日有233件病人轉床，延遲給藥進行追藥佔44.64％，平均每件轉床需花費41.78分鐘追藥。分析其問題爲：藥局得知轉床訊息不足、缺乏制定轉床病人給藥之標準作業程序、護理人員未確實點交藥物、護理人員對轉床病人注意事項及病人用藥安全在職教育宣導不足。依據決策矩陣分析擬定改善對策及執行並將之納入轉床病人藥物交班標準作業程序。結果顯示追藥百分比由44.64％降至9.34％，追藥耗時節省11.78分，本專案改善不但減少病人用藥安全疏失，並降低護理人員追藥時間，增加直接照顧病人時間，以提昇護理品質。

The aims of Patient safety include medicine used safety, so that we should take medicine used safety seriously. We found that patients of bedtransfer have medicine used delay and nurses take time to track medicine problem, by tab stat have 233 patients transfer bed on July 1st , 92 on July 31st, medicine used delay and nurses take time to track medicine up to 44.64%, average each patient of transfer bed need take 41.78 minutes to track medicine. Analyze the problems : pharmacy department didnt get information of transfer bed, lack of SOP of medicine used in transfer bed., nurses do not check medicine accurately, nurses do not accept enough job-training about how to care the patient of transfer bed and medicine used safety. According to decision matrix analyzes to make up plan-do-check-action procedures and set up SOP of medicine used in patient of transfer bed. The results show percentage of track medicine by 44.64% fall to 9.34%, track medicine economize 11.78 minutes. This case report not only decrease patient medicine used safety problems, but also reduce nurses the time of track medicine, and nurses have more time to care patients, so that we could promote the quality of nursing care.