某醫學中心護理人員給藥錯誤通報情形之調查研究

A Survey Study on Nurses' Medication Errors in a Medical Center

伍麗珠(Lih-Chu Wu) ； 林麗英(Lih-Ying Lin) ； 周惠千(Hui-Chien Chou)

《醫保研究雜誌》 1卷1期 (2005/03) Pp. 11-20

https://doi.org/10.29827/YBYJZZ.200503.0002

摘要

本研究旨在瞭解某醫學中心護理人員給藥錯誤的通報情形、給藥錯誤的實際情形、並比較實際給藥錯誤情形與全院給藥錯誤通報之落差。研究樣本爲該醫院38個住院單位之護理人員（共587）人，回溯民國90年1月至93年4月間之通報情形；另選擇一普通病房（護理人員15人）觀察其民國92年9月至93年4月間，護理人員實際給藥錯誤與通報之差異。結果顯示給藥錯誤通報件數有越來越多之趨勢；民國90年0件，91年1件，92年6件，93年1-4月爲7件。該等錯誤對患者之影響以患者須接受輕微監測(50%)或複雜監測(28.6%)者爲多；錯誤項目以劑量錯誤(35.7%)、藥物錯誤(28.6%)及病人錯誤(21.4%)較多；錯誤之發生時間以白班最多(78.6%)。在給藥錯誤低估情形方面，樣本單位8個月期間觀察到之實際給藥錯誤共49件，平均每月6.1件，但同一期間之通報件數爲0件，由此可知，通報錯誤件數顯著低於實際錯誤件數。由研究結果建議落實通報系統、抄錄藥囑作業電腦化、建立相關藥物資訊及加強各層級護理人員給藥作業訓練等，以改善給藥疏失，增進護理人員給藥的正確性。

關鍵字

給藥錯誤 ； 通報

並列摘要

The purposes of this study was to understand the medication errors reported by nurses, the errors found through a nurse head surveillance and the under estimations of the reporting system in a medical center. A retrospectively reported data collected from the period between January, 2001 and April, 2004 on medication errors of 587 nurses from 38 wards. There were other study subjects of 15 nurses in a ward observed by a nurse head from September, 2003 to April, 2004. The results indicated that the reported medication errors rising yearly, no case in 2001, one case in 2002, six cases in 2003 and seven cases in the first four months of 2004. In term of the patients' impact of the errors, 50% of the patients need to be monitored in a small extent and 28.6% in a complex extent. In the aspects of the misplace contents, the dosage mistake was the most popular (35.7%), followed by the category error of 28.6% and the medication-patient mismatch (21.4%). The errors happened more in the day time (78.6%) compared to the evening and the night time. Those errors reported by nurses were under estimated for the reason that forty-nine misplaced prescriptions were noted from a sample ward during an eight-month observation time, yet none of which were reported.
The errors needs could be avoided through the efforts on remodeling the reporting system, computerizing prescription record, establishing drug information network, and enhancing nursing in-service training.

並列關鍵字

medication error ； reporting system