護理人員給藥錯誤改善措施之效果評價

The Effectiveness in a Program to Improve Nurses' Medication Errors in a Medical Center

林麗英(Lih-Ying Lin) ； 伍麗珠(Lih-Chu Wu)

《榮總護理》 22卷3期 (2005/09) Pp. 239-248

https://doi.org/10.6142/VGHN.22.3.239

摘要

正確的給藥作業是保障病人安全的基本要項，而確實的通報是瞭解錯誤、改善錯誤的必要基礎。本部門於92年9月至93年4月調查某一42床的樣本單位，發現給藥錯誤共49件，但通報率卻爲0%，且在49件的給藥錯誤中，以抄錄藥囑至服藥記錄單30件(61.2%)爲最多，因此本研究以「護理人員給藥錯誤通報作業」及「給藥記錄單電腦化」爲介入措施，並比較有否實施該等措施對給藥錯誤發生的通報率及給藥錯誤發生率的影響。結果顯示「護理人員給藥錯誤通報作業」可提升給藥錯誤通報率（至48.7%）；將給藥藥囑電腦化，可顯著降低給藥錯誤率至與給藥紀錄單錯誤率(至0.007%)。建議進一步評價整體給藥作業的流程，以提昇整體給藥安全。

關鍵字

給藥錯誤 ； 通報系統 ； 給藥紀錄單電腦化

並列摘要

The correct medication procedure is the basis of patient safety, and the reported medication error is necessary to understand and to improve medication procedure. This concerns retrospectively reported data collected from the period between September, 2003 and April, 2004 on medication errors by 15 nurses in a ward. There were 49 medication errors, but the number of reported medication errors was 0. Transcription error was the most popular reasons of medication errors (61.2%). Therefore, this study intended to explore the effects of the reporting system and the computerizing medication record to replaced transcription. The results of this study were that the reporting system had increased the reported medication error rate, and the computerizing medication record had decreased the medication error rate. These results could increase the patient safety in regards to medication and increase the quality of medical care. So the lasting improvements are very important.

並列關鍵字

medication error ； reporting system ； computerizing medication recording