中部某醫學中心護理人員給藥錯誤現況及其相關因素探討

Survey on the status of nurses' medication administration errors and related factors at a medical center in central Taiwan

吳玉萍(Yu-Ping Wu) ； 李秋香(Chiu-Hsiang Lee) ； 李愛誠(Ai-Cheng Li) ； 陳美如(Mei-Ju Chen) ； 林卉姍(Hui-Shan Lin)

《醫療品質雜誌》 13卷6期 (2019/11) Pp. 44-50

https://doi.org/10.3966/199457952019111306009

摘要

目的：探討護理師給藥錯誤情形，進而瞭解護理師的基本屬性與給藥錯誤之間的相關性，以提供臨床針對病人安全防範之參考。方法：採回溯性研究設計，自2013年至2015年間以護理師主動通報之給藥錯誤事件作為資料來源，並以SPSS 21.0版進行分析，以描述性統計法分析樣本屬性及給藥錯誤現況，以卡方檢定分析各變項間的相關性。結果：給藥錯誤總件數為64件。部門以內科病房居多（32件），傷害程度以輕度傷害居多（27件），錯誤發生類別多為病人辨識錯誤（22件），藥物劑型以注射型居多（34件），發生可能原因大多為人員個人因素（51件）；病人年齡、藥物劑型兩者與發生部門達顯著差異（p ＜0.05），病人性別、病人年齡及藥物分類此三項與傷害程度上達顯著差異（p ＜0.05）。結論：護理師給藥時需落實三讀五對的規範。護理主管應加強護理師對於給藥之認知，並分析事件發生的真正原因，減少給藥錯誤事件發生。

關鍵字

護理師 ； 給藥錯誤 ； 異常事件

並列摘要

Purpose: The purpose of this study was to investigate the circumstances of nurses' medication administration errors and to explore the correlation between basic attributes of the caregiver and medication administration errors. Our results provide a clinical reference for promoting patient safety. Methods: This is a retrospectively designed study conducted during 2013-2015. During that time, medication administration errors reported by nurses were recorded. SPSS 21.0 was used for data analysis. Descriptive statistics were used to analyze the sample attributes and the status of drug errors. The correlations between all variables were analyzed using chi-square tests. Results: The total number of medication administration errors was 64. Administration error eventsoccurred mainly in the wards of the internal medicine department (32 events), and the severity of these errors was mostly minor (27 events). The majority of the errors were patient identification mistakes (22 events), and the drugs were primarily administered through injection (34 events). Personal factors (51 events) were the most attributable cause for error occurrence. Patient's age, drug form, and the department where the events occurred were remarkably different (p ＜ 0.05), whereas patient's gender, age, and drug classification were significantly correlated with the degree of injury (p ＜ 0.05). Conclusions: Nurses must implement the ＂Three-Read＂ and ＂Five-Rights＂ regulation when administering medication. Nursing supervisors should increase nurses' awareness of drug administration, analyze the true cause of erroneous events, and endeavor to reduce the incidence of drug administration errors.

並列關鍵字

nurse ； medication administration error ； adverse event reporting