提升病歷首頁用藥過敏史註記完整率

「病人安全」為各國醫界與社會關注的焦點，如何落實醫師詢問病人藥物過敏史及建立藥物過敏註記於病歷首頁，降低病人發生藥物過敏之風險，提升醫療照護品質，進一步來保障病人之安全。目的：本研究希冀提升病歷首頁用藥過敏史註記完整率。本抽查期間平均藥物過敏史註記完整率76%，目標定為註記完整率達95%以上。方法：以PDCA模式，針對所欲解決之問題進行專案改善之過程。申報人員於98年1月1日至98年5月31日期間，費用審查時抽審1254本病歷，統計分析病歷首頁用藥過敏史註記之情形。結果：，經分析與確認問題後，制定改善對策，實施期間：民國98年6月至9月。本計畫實施之後，達到96.6%之完整註記率。結論：再好的機制，若未有確實之執行與落實，仍可能功虧一簣。本文建議（一）設定藥物過敏史及不良反應史的登錄流程。（二）未完整病歷不入庫原則。

關鍵字

病人安全；藥物過敏

並列摘要

Patient-safety has become the focus of healthcare services in Taiwan recently. Correctly alert patients allergy history in the cover of the patients medical record is critical to prevent medical errors while prescribing, of which will in turn ensure service quality of healthcare and safety of a patient. Purpose: this project attempts to improve the correct rate of allergy marking from current rate of 76% to 95% or above. Methods and materials: A PDCA model is adopted, and 1254 cases of medical records of a hospital are used to analyze in the period between January 1st and May 31st 2009. Results: several meetings are called to identify causes, to establish an improvement scheme, and then to-complete an improvement project. The correct rate of proper marking of a patients allergy history has greatly improved to a rate of 96.6%. Conclusion: Effective management in implementing the improvement project is essential for the success. Therefore, it is suggested that (1) Establish a formal process of allergy history marking, and include this process as part of a regular office work standard;(2)establish a standard operation process that refuses to file incomplete record.

並列關鍵字

Drug allergy ； Patient safety ； PDCA

國際替代計量

提升病歷首頁用藥過敏史註記完整率

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