提升某精神專科急性病房院外醫藥品給藥程序完整率

用藥安全是醫療品質及病人安全重要的工作項目，其中包含院內及院外藥品，但本院臨床人員並未確實執行院外藥品給藥程序且做法不一，病人用藥安全實為堪慮，故組成專案小組對此問題進行改善，經由專案小組稽核，院外藥品給藥程序完整率只有5.6%。依80/20法則確立問題為：未制定制式藥品確認單、醫護人員認知不足、家屬未帶回處方箋、醫護人員未落實院外藥品處置流程、醫護人員對常規作業不熟悉、院外藥品處置流程實施宣導不足。經由參考文獻及專案小組討論後，擬定對策有：制定外診藥品審視建議單、制定院外藥品給藥程序書、辦理跨科室協調會議、制定稽核機制、安排教育訓練、安排科室主管宣導會議、製作個別提醒貼紙、舉辦生活討論會等。經改善措施後，院外藥品給藥程序完整率提升至100%。本專案經驗可供同屬性醫療院所參考，加強跨科室的溝通協調與合作，真正落實院外藥品給藥流程，才能在病人用藥安全上做把關。

關鍵字

給藥系統；病人安全；品質確保

並列摘要

Medication safety is important in quality of healthcare and patient safety, among which both medicine from and outside the hospital is included. In local practice, we have found that first-line staff usually failed to comply with the procedures of managing the medicine from outside the hospital where it might impose threats upon medication safety. We, thus, organized a team to execute the project to audit and improve this problem, and found that there was only 5.6% of completion during the whole procedures of managing the medications from outside the hospital after initial assessment. According to 80/20 rules, lack of standard confirmation sheet, inadequate recognition of the staff, lack of original prescription, without compliance with the procedures, unfamiliarity with medical routines, and insufficient propaganda were identified as main problems. After going through literature review and having team discussions, we formulated the improvement strategies which included drafting the inspection and recommendation form, setting up quality procedures for administrating medications from outside the hospital, holding inter-departmental discussion meetings, establishing regular scrutinizing mechanism, hosting education training, encouraging the administrators and patients and printing reminding stickers. The rate for completing quality procedures for medication from outside the hospital has increased to 100% at the end of the project. Our experience can be as an example for the hospitals with similar features to enhance inter-departmental communication and cooperation, further to fulfill medication administrating procedures, and to ensure patient under better medication safety eventually.