護理人員給藥錯誤認知之探討

Nurses' Perceptions of Medication Errors

本研究的目的在探討護理人員對於造成給藥錯誤原因、給藥錯誤情境及給藥錯誤通報的認知。採問卷調查法，於民國93年11月以某醫學中心的護理人員為調查對象，隨機抽樣，問卷發出180份，回收168份，有效問卷為160份。研究工具包括基本資料表、發生給藥錯誤的主要原因、護理人員對5種給藥情境的認知，判斷是否為給藥錯誤，是否會通知醫師及是否會進行藥物異常事件通報及護理人員對給藥錯誤及通報的認知。研判結果顯示：(一)護理人員認為容易造成給藥錯誤的相關因素為『護理人員給藥時又同時被其他病人、同仁或單位內其他突發事件所中斷或干擾』為最高，其他依序為『護理人員疲勞及精疲力盡的時候』、『兩種藥名相似的藥物造成混淆』及『醫師手寫處方簽難以辨識或電腦處方說明不清楚』；(二)護理人員對五種給藥情境的判斷答案一致性低，工作單位與給藥情境反應多項具有統計學上顯著差異，大部分的情境都會通知醫師，但不會進行藥物異常事件通報；(三)護理人員給藥通報的認知，「因害怕給藥錯誤會影響護理主管與同儕對自己的看法，故隱匿不報」，遠高於「害怕受到處罰或失去工作」。研究結果可應用作為教學及在職教育的參考題材，藉以提供促進護理人員對給藥錯誤辨識課程的規劃，並減低或排除通報障礙。

The purpose of this study was to describe perceptions of nurses in a teaching hospital inTaiwan about what qualifies as a medication error and the causes of medication errors. Four selfreportquestionnaires were used in this study: demographic data; nurses'perceived causes of medicationerrors; types of incidents that would be classified as (1) medication errors, (2) reporting tophysicians, or (3) reporting by an incident report; nurses'views on reporting medication errors.The causes of medication error included distraction, fatigue, exhaustion, confusion between twodrugs with similar names, and illegibility of physician's orders. The reasons for not reporting medicationerror included fear of nursing managers'and peers'reaction. The study findings can be usedin programs designed to promote medication error identification and to reduce or eliminate barriersto reporting.