運用團隊資源管理於提升兒科加護病房新進護理師給藥安全

Application of Team Resource Management in Enhancing the Medication Administration Safety of New Nurses in Pediatric Intensive Care Units

高蔚怡(Wei-Yi Kao) ； 林佳慧(Chia-Hui Lin) ； 陶菁(Ching Tao) ； 李晴玉(Ching-Yu Lee)

《高雄護理雜誌》 34卷3期 (2017/12) Pp. 36-47

https://doi.org/10.6692/KJN.201712_34(3).0004

摘要

當發生給藥錯誤，兒童的死亡風險高出成人許多，對新進護理師而言更是導致強烈挫敗感，甚至為離職之主因。本專案目的在提升兒科加護病房新進護理師之連續性靜脈給藥安全。運用團隊資源管理，加強團隊合作及溝通來提升醫護間訊息傳遞及病人安全。經現況查檢發現新進護理師執行連續性靜脈給藥流程中因藥物劑量及資訊缺失率佔19.6%，而導致缺失前四項原因依序為：醫囑複雜且無標準、藥物劑量計算困難、藥袋資訊雜亂、缺乏規範與在職教育。經整合醫療團隊資源後擬定策略有：增設電腦自動計算劑量欄位、調整藥袋資訊內容、設計便利貼輸液卡、修訂新進護理師學習歷程、增加用藥安全在職教育及制訂連續性靜脈給藥規範。實施後連續性靜脈給藥缺失率降至0.6%，給藥異常事件為0 件。

關鍵字

團隊資源管理 ； 新進護理師 ； 連續性靜脈給藥 ； 用藥安全

並列摘要

When medication errors occur, the mortality rate in children is much higher than in adults, which makes new nurses feel frustrated, and is a main cause of resignation. This project was designed to enhance the patient safety of continuous intravenous drug infusion by new nurses in PICU patients by application of Team Resource Management, enhancing cooperation and communication between teamwork, and reducing teamwork-related incidents. According to recent analysis for assessing the procedures of continuous intravenous drug infusion by our new nurses, the incompletion rate related to lack of drug information accounted for 19.6%. The top four reasons were: complex orders given without standard prescription; difficulty in calculation for drug doses; lack of organized pharmacy information; and lack of continuous intravenous drug infusion standard and further training. By medical resource integration, the strategies included setting a double-check nursing information system for drug doses calculation, adjusting the pharmaceutical information content, designing the information card for the continuous intravenous drug infusion, emending new nurses’ learning courses, enhancing education for safety drug administration, and standardizing the steps for continuous intravenous drug infusion. After the above strategies were implemented, the continuous intravenous drug infusion incompletion rate in new nurses decreased from 19.6% to 0.6% without any adverse events.

並列關鍵字

Team Resource Management ； new nurse ； continuous intravenous drug infusion ； medication safety

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