降低兒童病房護理人員給藥中斷率

Reducing the Rate of Drug Administration Interruptions for Nurses in Pediatric Ward

兒童給藥過程發生中斷將影響用藥安全，單位給藥過程中斷導致給藥錯誤事件共3件，故引發改善動機。專案小組調查發現中斷率高達14.5%，問題包括：護理師給藥前沒有先處理病人點滴問題、未提供醫護團隊給藥不中斷教育及宣導，輕忽風險、護理師給藥時辨識度不足及家屬不知給藥中斷風險不知給藥時不可打擾。專案目的為運用跨團隊改善策略降低中斷比率，解決辦法包括：給藥前先檢視點滴問題及處理、舉辦給藥不中斷教育、跨部門宣導給藥不中斷內容、使用給藥中勿打擾告示牌及海報、說明單衛教家屬。結果給藥中斷率由14.5%降至6.1%，中斷造成給藥錯誤降為0件。藉由跨團隊合作策略能有效降低給藥中斷發生率及給藥風險，提升用藥安全。

The interruption of drug administration in children will affect the safety of medication, and the interruption of drug administration in the unit led to a total of 3 drug administration errors, which triggered the motivation for improvement. The investigation by the task force found that the interruption rate was as high as 14.5%. The problems included: the nurses did not deal with the patient's drip before administering the medicine; the medical team did not provide education and publicity on the uninterrupted administration of the medicine, ignoring the risks; the nurses did not have enough recognition when administering the medicine; Family members who do not know the risk of interruption of drug administration should not disturb when they do not know the risk of drug administration. The aim of the project was to reduce interruption rate using interdisciplinary team improvement strategies. The strategies include: check the drip problem and deal with it before administering the drug, organize education on non-interrupted administration, publicize the content of non-interrupted administration across departments, and use the Do Not Disturb notice during administration Cards and posters, and use the instruction sheet for educating family. Results The interruption rate of administration decreased from 14.5% to 6.1%, and the number of administration errors caused by interruption decreased to 0. Interdisciplinary team cooperation strategy can effectively reduce the incidence of drug interruption and the risk of drug administration, and improve drug safety.