導入客觀性結構式臨床測驗降低新進護理人員給藥錯誤發生率

Applying Objective Structured Clinical Examination to Improve Medication Administration Errors in New Nursing Staff

病人安全通報事件中給藥錯誤多為首位，其中年資一年以下的護理新進人員為給藥錯誤的高發生群體，本院 2014 年因擴院招募新進人員，給藥錯誤率隨之攀升，現況分析分析發現年資未滿一年人員給藥錯誤發生率攀升至 0.035%，原因主要為「未確實執行給藥流程」、「人員疏忽」、「臨床訓練不足」及「臨床教師缺乏教學評估量表教學課程」。本專案目的為降低年資未滿一年新進人員給藥錯誤發生率。2014 年 11 月起導入給藥技術的客觀結構式臨床能力測驗進行改善，並針對臨床教師辦理臨床教學評量工作坊。專案執行後，年資未滿一年給藥錯誤發生率由 0.035% 下降為 0.014%，達到專案目標，確知客觀結構式臨床能力測驗可有效改善新進人員給藥錯誤事件，因而可作為日後臨床能力相關品管指標精進參酌。

Medication errors are the most commonly reported cases during patient safety reporting. New nurses with less than one year of experience have the highest incidences of medication errors. The Hospital recruited several new nurses in 2014 in response to hospital expansion, and medication error rates have increased since then. An analysis of the current situation shows that the incidence of medication errors by new nurses with less than one year of experience has increased to 0.035%, mainly due to failure to implement the drug administration process, personnel negligence, insufficient clinical training, and lack of teaching assessment courses for clinical teachers. The purpose of this project is to reduce the incidence of medication errors among new nurses with less than one year of experience. The Objective Structured Clinical Examination (OSCE) for drug administration techniques was introduced in November 2014, and clinical teaching assessment workshops have been provided to clinical teachers. After the implementation of the project, the incidence of medication error of new nurses with less than one year of experience dropped from 0.035% to 0.014%, which means the project successfully achieved its goal. The OSCE can effectively reduce the medication errors of new nurses, and thus it can be used as a reference for the improvement of relevant quality control indicators of clinical ability in the future.