護理人員對給藥錯誤原因看法之初探

Reasons for Medication Errors from a Nursing Perspective

林麗珍(Lih-Jen Lin) ； 陳淑嬌(Shu-Chiao Chen) ； 李麗雲(Li-Yun Lee) ； 蘇麗惠(Li-Hui Su) ； 畢耜春(Su-Chun Pi) ； 李小凰(Hsiao-Huang Lee) ； 林綽娟(Chouh-Jiaun Lin)

《Mid-Taiwan Journal of Medicine》 12卷3期 (2007/09) Pp. 157-165

https://doi.org/10.6558/MTJM.2007.12(3).5

摘要

目的　本研究係以橫斷式研究法探討雲嘉地區醬院護理人員對於給藥錯誤原因之看法。
方法　本研究係以橫段式研究法探討護理人員的看法。294位研究對象係六個雲嘉地區醬院之內外科病房的護理人員。研究工具係以自擬之結構式問卷問卷包括給藥錯誤的原因與預防策略。研究工具經專家效度(CVI=81.3)及再測信度(0.78)的檢定。
結果　研究結果顯示護理人員認為給藥錯誤原因是：1)藥師將藥物裝錯(92.2%)，2)藥品外觀相似(87.0%)，3)遺漏確認病人(84.9%)，4)未執行三讀五對(81.8%)，5)工作被中斷等(80.4%)。
結論　護理人員落實給藥標準流程、醬囑電腦化、檢視護理人員工作負荷及工作環境等將有助於減少給藥錯誤的發生。

關鍵字

給藥錯誤 ； 給藥安全 ； 護理人員

並列摘要

Purpose. The purpose of this study was to explore the reasons for medication errors among health care professionals from a nursing perspective.
Methods. This was a cross-sectional study of 294 nurses recruited from medical-surgical wards of six district hospitals in Yun Lin County, Taiwan. An instrument designed to measure nurses' perspectives of the reasons for medical errors made by health care professionals was administered to all 294 nurses. The instrument measured reasons for medication errors and strategies to prevent them. The content validity index (CVI = 81.3%) and test-retest reliability (r = 0.78) showed that the questionnaire was a valid and reliable instrument.
Results. The participants indicated the following reasons for medication errors: (1) pharmacists provided wrong medicines (92.2%); (2) packaging of many drugs was very similar (87.0%); (3) nurses did not recheck patients' names (84.9%); (4) nurses did not recheck the medicine before giving it to patients (81.8%); and (5) nurses were interrupted during the process of preparing medication (80.4%).
Conclusion. Medication errors can be minimized by implementing standard medication-delivery procedures, computerizing prescriptions, decreasing nurses' workload and improving their work environment.

並列關鍵字

medication error ； medication safety ； nurses