降低病人操作胰島素筆型注射器錯誤率方案

A Project to Reduce the Rate of Operational Mistakes in Using Insulin Pen Injection Device among Diabetic Patients

鄭淑芬(Su-Fen Cheng) ； 陳玲珠(Lin-Chu Chen) ； 吳婷婷(Ting-Ting Wu) ； 宋素真(Su-Chen Sung)

《榮總護理》 23卷4期 (2006/12) Pp. 393-402

https://doi.org/10.6142/VGHN.23.4.393

摘要

本專案旨在使病人操作胰島素筆型注射器錯誤率由43.3%降至15.9%以下。組員於2004年8月調查發現，出院前評值病人胰島素筆型注射器操作錯誤率為43.3%，經分析發現原因有：衛教工具不足、未定期監測衛教成效、護理人員技術不熟練且認知不一致及未建立標準作業流程等四項問題，導致病人錯誤率偏高。故成立專案小組，擬定四項解決辦法：制訂胰島素筆型注射器衛教單張、標準盤及衛教光碟;成立稽核小組;安排胰島素筆型注射器操作知識、技術及衛教技巧之在職教育;訂定胰島素筆型注射器衛教標準流程。經措施執行後，病人操作筆型注射器錯誤率降至10%，達到設定之目標。顯現本專案具改善成效，期望此專案能持續施行及監測，確保病人得到更好的護理指導品質。

關鍵字

胰島素筆型注射器 ； 護理標準與品質稽核 ； 護理指導

並列摘要

This project has fulfilled the purpose of reducing the rate of operational mistakes committed by patients while using insulin pen injection device from 43.3% to 15.9%. Through the investigation conducted in August 2004, team member disclosed that the rate of operational mistakes committed by patients in using insulin pen injection device before discharge was 43.3%. The analysis demonstrated four predisposing factors as follows: inadequate teaching tools for health education, lack of monitoring the efficacy of health education on a regular basis, poor proficiency in the technique and cognitive deficiency of the nursing personnel, and the absence of establishment of the standard operational procedures, respectively. All these four problems led to the high rate of mistakes among the patients. A special team was established and the proposal of resolutions for the problems was laid as follows: production of health education leaflets for the operation of insulin pen injection device, standard tray and floppy disc, founding of an audit team, organization of on-job education to teach skills of health education, technique and operational knowledge for using insulin pen injection device, and setting up of algorithm for the health education for using insulin pen injection device. Upon implementation of these measures, it was found that the rate of operational mistakes committed by patients when using insulin pen injection device dropped to 10%; thereby achieving the established goal. It indicates that this project contributes to effective improvement. We expect this project to be carried out continuously to monitor and ensure better quality of nursing instruction for the patients.

並列關鍵字

insulin pen injection device ； nursing standard ； nursing education