- 學位論文
減少醫療人員給藥錯誤的機制探討：以個案醫院為例
The Mechanism Established to Reduce Nursing Medication Errors: A Case Study
摘要
醫院藥局給藥錯誤是臨床實踐中常見的問題，對病患的治療效果和安全性造成了嚴重影響。給藥錯誤主要指在醫療過程中，藥事人員在開藥、調劑、給藥等環節中出現的錯誤，包括藥物選擇錯誤、劑量計算錯誤、藥物劑型錯誤、給藥途徑錯誤等。這些錯誤導致病患的不良反應、藥物過量或不足等問題，嚴重情況下甚至會危及病患的生命。基於此，本文針對給藥錯誤事件存在的具體問題及原因進行分析，探討預防給藥錯誤事件發生，為保護患者用藥及生命健康安全提供參考。 本研究透過對個案醫院藥局給藥錯誤事件進行研究，提出減少給藥錯誤的方法和策略。研究發現，醫院藥局管理和醫師、護理師的操作是影響錯誤發生的關鍵因素，並且給藥錯誤中以給藥數量錯誤佔比較高。針對給藥錯誤存在的具體原因，本文提出了針對性建議，主要包括：建立完善的藥物管理系統、提高對患者身份識別的準確性、重視醫療人員及病患安全文化的建設、定期提供專業培訓與教育、導入智慧化技術和設備、加強醫護團隊的跨領域參與以及改善醫療團隊合作和溝通，以期有效減少醫院給藥錯誤的發生。 本研究提出給藥錯誤的方法和改進方案，以提高醫院給藥安全性。未來可加強台灣各醫院及各國家之間的經驗交流和合作，透過分享最佳實踐和合作研究，共同努力提高病患的給藥安全性和臨床治療效果。
並列摘要
Medication errors in hospital pharmacies are a common problem in clinical practice, which have a serious impact on the efficacy and safety of patient care. Medication errors, mainly referring to errors made by pharmacists in the process of prescribing, dispensing, and administering medications during the medical process, include errors in the selection of medications, dosage calculation, dosage form, and route of administration, etc. These errors may lead to adverse reactions, overdose or underdose, and may even endanger the patient's life in serious cases. Therefore, this thesis analyses these specific problems and causes of medication errors, in order to provide a reference for rapid screening of medication errors, prevention of medication errors, and protection of patients' medication for patients’ health and life safety. This study firstly summarized existing methods and strategies to reduce medication administration errors by conducting an in-depth study of medication administration errors in hospital pharmacies. The study found that hospital pharmacy management and physician and nurse practices are key factors influencing the occurrence of errors. Currently, medication errors are prevalent, and the number of medications administered accounts for a high proportion of medication errors, and patient and family satisfaction levels are relatively low. To address the specific problems of medication administration errors, this paper proposes specific recommendations, which mainly include establishing a comprehensive medication management system, improving the accuracy of patient identification by caregivers, focusing on the construction of a culture of patient safety, providing professional training and education on a regular basis, introducing intelligent technology and equipment, enhancing patient and family participation, and improving healthcare teamwork and communication with the aim of effectively reduce the incidence of medication errors. This study provides a useful reference for improving the safety of medication administration in hospitals by exploring methods and improvement options to reduce medication administration errors. Enhancing the exchange of experiences and cooperation among hospitals in Taiwan and among countries is an important direction for future research. By sharing best practices and collaborative research, joint efforts can be made to improve the safety of drug administration and clinical outcomes for patients.