降低住院病人自備藥給藥異常發生率專案

背景：給藥異常影響病人安全，現況分析發現本單位2014年第一季病人給藥異常發生率驟增至16.3%，居全院之冠。歸納分析發現自備藥給藥異常發生率佔所有給藥異常事件71.4%居首位，其中66.7%為自備藥管理不當所造成。目的：降低自備藥給藥異常發生率至3%及提高自備藥管理的正確率至90%。材料與方法：為使病人獲得更安全的用藥環境，故成立專案小組，由護理師、醫師及藥師跨團隊合作，進行（1）修訂標準作業流程，（2）製作文宣提醒卡置於床頭，（3）製作自備藥工作櫃，（4）舉辦在職教育，及（5）制定稽核制度，以改善自備藥給藥異常情形。結果：本單位自備藥給藥異常發生率由71.4%降至3%，自備藥管理正確率由69.6%提升至95%。結論：本專案執行之措施，確實能降低自備藥的給藥異常發生率及提高自備藥管理的正確率，達到此專案之目標。

Background: Adverse medication event impacts on patient’s safety. The incidence of adverse medication event in our unit increased to 16.3% during the first season in 2104 and was the highest in the hospital. We analyzed this issue and found inpatients took medicine preparing by themselves resulted in 71.4% of adverse medication event, of which 66.7% was inaccurate inpatients’ self-prepared medicine management.
Purpose: The purpose of this project was to decrease the incidence of adverse medication event to 3%, and to increase the correct rate of self-prepared medicine management to 90%.
Resolutions: A cross-disciplinary collaboration team including three registered nurses, a doctor and a pharmacist was set up and we revised the standard of procedures, posted reminding card at bedside, provided every patient a personal medicine box to use, conducted nursing in-service education, and internal auditing were built to improve the inpatients’ self-prepared medicine management.
Results: The incidence of adverse medication event decreased from 71.4% to 3%, and the correct rate of medicine management increased from 69.6% to 95%.
Conclusion: The result of this project has reached the goal to decrease the adverse medication event increased the correct rate of inpatients’ self-prepared medicine management.