- 期刊
提升內科病人自備藥物管理改善專案
A Project to Improve Drug Safety of In-Patient Self-Prepared Medication
摘要
避免重複用藥、提升病人用藥安全，是近年病安之重要議題，亦是2016年衛生福利部病人安全年度目標之一。本院針對住院病人於住院期間，會要求將其長期服用的藥物帶院使用（簡稱：自備藥物），由護理站管理，然臨床照護中發現病患出院時護理人員未能即時歸還自備藥物，造成病人用藥問題。統計2015年單位自備藥物未歸還率高達13.8%引發專案小組改善動機，期望透過專案之執行能避免重複用藥、提升病人用藥安全。改善前發現問題為護理人員對自備藥之管理認知及操作不正確、無交班流程、儲放設備位置不當和缺乏查核機制，透過制定自備藥物護理交班及管理流程作業、採購自備藥物櫃及刻印自備藥物章、舉辦教育課程和與資訊室合作新增自備藥物藥囑系統等介入性措施，以達改善之目的。
並列摘要
Prevent duplicate medication and improve drug safety for patients are two critical issues of patient safety in the recent years, as well as the 2016 Annual Patient Safety Goal released by the Ministry of Health and Welfare. The hospital policy requires patients to hand over their chronic medication (Patient's Own Medication, POM) to the nursing unit upon admission. However, it was identified that in clinical nursing, the POMs were not returned upon patients' discharge, resulting in patient medication issues. According to the 2015 census, the rate of POMs not returned to the patients were as high as 13.8%, which resulted in the planning of this project. The aim of this project was to prevent duplicated medication and improve drug safety. After literary review and incident investigation, the following problems were identified: inadequate cognition and incorrect handling of POM, no SOP for POM during shift change, inappropriate POM storage, and lack of routine internal audit. The project included the following improvements: establishing a SOP for POM during shift change, initiating on-job training program, cooperating with the information office in developing an order entry system for POM, purchasing dry cabinets for POM storage and engraving seals for POM labeling and management. With the implementation of these interventions, we expect to see improvements in the handling and storage of POM in the future.