某加護病房護理人員執行給藥作業之改善方案

Improvement of Intensive Care Unit Medication Administration

蘇佩真(Pei-Chen Su) ； 徐盈真(Ying-Chen Hsu) ； 張羽婕(Yu-Chieh Chang) ； 林盈慧(Ying-Hui Lin) ； 張瓊櫻(Chiung-Ying Chang)

《高雄護理雜誌》 29卷2期 (2012/08) Pp. 25-39

https://doi.org/10.6692/KJN-2012-29-2-3

摘要

「給藥作業」是高頻率護理工作，本加護病房因為給藥作業環境凌亂無章導致給藥錯誤，故著手改善護理人員執行給藥作業。經調查護理人員執行給藥作業不正確率為12.7％，經訪談、分析並確立問題為：兩床共用一台工作車、工作車擺放擁擠且凌亂、夜間病人單位燈光不足、工作車設置地點不佳、人員未確實或未核對即憑印象給藥。參考文獻及發揮創意並擬定五項對策包括：修訂給藥相關作業流程、製作海報、改善備藥環境、設計置藥工作櫃、建立稽核制度等，於實行改善措施後，護理人員執行給藥作業不正確率由12.7％下降為0％及給藥錯誤發生件數為0件，本專案的實施，確實改善護理人員執行給藥作業之不正確及提升給藥流程順暢，給予病患更好的護理品質。

關鍵字

給藥作業 ； 給藥安全 ； 加護病房

並列摘要

Issuing medication is a high priority, most demanding, stressful and responsible part of nursing work. Any outside disturbance and disorder can influence this process and result in some disorganization during the medication process, thus having potential risk for improper medicines to be administered to patients.
Our investigation has shown that the percentage of administering wrong medicines is 12.7%. Interviews with related nurses revealed the root-cause-analysis as follows: (1)Storing different medicines for different patients without a proper order on the working-cart; (2) Working environment, as nurses are preparing the medicines near the patients, therefore in particular, insufficient lighting conditions existing at nighttime as the patients are sleeping; (3) No standard procedure for the working carts, e.g. a fixed place, so as a result, nurses are using it individually; and (4) Nurses in general, do not follow the standard procedure as to how to issue medicine to patients.
Based on historical medical documents, we identified the following solutions: (1) Standardize medication-dispensing procedures; (2) Prepare a post of standard procedure for internal reference only; (3) Improve the environment of medication preparation, e.g. an external room; (4) Redesign the working-table; and (5) Create an auditing process for internal reference only.
All nurses following the new standard procedure should result in less mistakes made when giving out medicines and thus the inaccuracy rate of medication will drop significantly after improvement. By implementation of this project, nurses should be able to amend the accuracy of general medication and elevate the safety of using medications. As a result, patients will receive a better quality of nursing.

並列關鍵字

medication administration ； medication safety ； intensive care unit