建置藥品簽收系統以提升閉環給藥之藥品動向品質

Establishing a Medication Receipt System to Enhance the Quality of Medication Flow in Closed-Loop Administration

目的：條碼系統和閉環流程搭配使用可以降低給藥錯誤。檢視目前系統僅藥品調劑完成領送回病房階段尚無透過條碼掃描串接資訊紀錄，人員難以掌握藥品動向，可能造成延遲給藥、藥品遺失等異常事件。

方法：運用問題解決型找出4項真因為：護理師不知道藥品是否領回、缺乏系統紀錄傳送人員姓名、輸送人員送錯單位難以確認藥品動向、缺乏系統紀錄傳送時間，進而擬定對策。

結果：藥品動向之異常事件數由改善前1件，目標為0件，改善後降至0件。1至3級管制藥藥品簽收點交率改善前無資料，目標為100%，改善後達100%。

結論：本次改善專案透過資訊系統建置完善閉環流程，成效良好推廣至體系醫院共同提升用藥安全。

 

Objective:Integrating a barcode system with closed-loop medication administration can reduce medication errors. A review of the current system reveal thatbarcode scanning is not utilized to records of medication receipt at the stage of dispensing and returning medications to the wards. Thus, lack of tracking makes it difficult for staff to monitor medication flow, potentially leading to delays administration, medication loss, and other incidents.

Methods: In this study, a problem-solving model was applied, and thefollowing four causes of the aforementioned challenges were identified: nurseswere unable to confirm whethermedications had been retrieved, no system was available to record the name of the person delivering the medication, the current system was difficult to track medication flow when the medication sentto wrong unit, and no system was in place to record the time of delivery in order to formulate a plan of action.

Results:The number of incidents related to medication flow was reduced from 1 to 0. The rate of medication receipt and handover ratefor Class 1–3 controlled drugs was no prior data, with a target set at 100%, which was successfully achieved afterimplementation.

Conclusion: This project improved the closed-loop medication administration process through the establishment of an information system.Given its effectiveness, the system has been promoted across affiliated hospitals to enhance medication safety.