運用資訊系統降低給藥錯誤率之專案

Applying Information System to Reduce Medication Errors

郭旭展(Hsu-Chan Kuo) ； 翁素華(Su-Hua Weng) ； 蘇淑芳(Shu-Fang Su) ； 鄒淑萍(Shu-Ping Chou)

《精神衛生護理雜誌》 13卷1期 (2018/06) Pp. 44-52

https://doi.org/10.6847/TJPMHN.201800_13(1).06

摘要

病人安全為醫療品質的根本，給藥錯誤除了造成病人身體傷害外，亦影響護理師自信心及情緒，甚至傷害護理專業形象。本院雖然訂有標準作業流程，但2013年7月至2014年1月間仍發生五件給藥錯誤事件（0.00527%）。為降低給藥錯誤率並確保病人安全，本院組成專案小組進行調查分析後發現，謄寫醫囑錯誤、醫師字跡潦草、核對醫囑耗時、未依標準流程核對病人及欠缺即時查核機制為導致錯誤之主因。專案小組以團隊資源管理模式設計資訊系統、編修相關流程、舉辦教育訓練及定期稽核，成功將給藥錯誤率降至十萬分之1.05，改善幅度高達80.07%，顯示資訊系統之啟用確實有效且可廣泛運用。

關鍵字

資訊系統 ； 給藥錯誤 ； 病人安全

並列摘要

The quality of medical service can be concluded from the degree of safety the patients obtain. Medication error causes physical harm to patients, negatively affects nurses' confidence and emotions, and damages the image of professional nursing institutions. Although our hospital follows strict standard of operating procedures, five instances of medication error (0.00527%) still occurred during the period of July 2013 and January 2014. To lower the rate of medication error and to ensure patient safety, we formed a special team to carry out an investigation and analysis, which showed that incorrect transcribing medication orders, illegible physician handwriting, a great length of time required to verify doctor's orders, a failure to verify patients' information in compliance with the standard procedure, and a lack of an immediate verification system were the primary causes of such errors. By using a team resource management model, we designed an information system, modified related procedures, hosted education and training programs, and performed regular reviews. Such endeavors successfully lowered the rate of medication error down to 0.00105% (an improvement of 80.07%) and verified the new system's effectiveness and generalization.

並列關鍵字

information system ； medication errors ； patient safety

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