降低靜脈輸液化學藥物外濺發生率專案

A Project to Reduce Spilling Incidence of Chemotherapy Drugs During Intravenous Infusion

化學藥物外濺會造成人員、環境危害及醫療成本浪費，專案單位於2008年10月至2009年3月外濺發生率0.41%，占全院41.67%，故希望藉由專案執行降低外濺率發生。經事件分析及查檢表發現主要原因為:輸液架功能不良、護理人員執行注射器插入軟袋技術不正確、預防化學藥物外濺護理指導未落實、及疏於輸液管路安全維護。專案執行期間自2009年5月至2010年9月，針對原因進行改善方案：制定及執行輸液架清潔管理辦法、擬定輸液器插入軟袋標準及教學、建立預防化學藥物外濺護理指導標準及評估表，並參與全院性會議，建議增購設備及引進新醫材。專案執行後，化學藥物外濺率下降至0%，達到目標值0.15%；希望專案執行策略有效提升化學治療與環境安全品質，希冀藉本文與護理同道分享。

The spilling of chemotherapy drugs can cause personnel and environmental hazards and a waste of health care costs. The spilling incidence of the project unit was 0.41% during the period of October 2008 to March 2009, which accounted for 41.67% of the total incidents in the hospital. The goal is to reduce the occurrence of spilling incidences through project execution. Based on the fi ndings of event analysis and checklist, the main problems were: incorrect process of syringe into soft bag conducted by nurses; infusion rack dysfunction; nurses not providing chemotherapy drugs spill self-prevention guidance to patients; and no periodical monitoring of the infusion tube connection. The project execution period was from May 2009 to September 2010. The improvement program included: setting up the infusion into the soft bag standard procedures and teaching the nurses to set up and implement the infusion rack cleaning procedures; establishing the guiding standards of the chemotherapy drugs spill self-prevention measures and the cognitive evaluation form; and participating in hospital-wide meetings for the purchase of equipment and the introduction of new medical materials. After the project implementation, the chemotherapy drugs spill rate dropped to 0%, reaching 0.15% target rate. By using the improvement program, the quality of chemotherapy and environmental safety were enhanced and it might provide a guideline for nursing staff.