Implementing a High-alert Medication Policy

實施高警訊藥物作業管理政策

楊麗影(Li-Ying Yang Bridges)

《源遠護理》 1卷2期 (2007/05) Pp. 30-41

https://doi.org/10.6530/YYN.2007.1(2).04

摘要

護士在病人安全中扮演守門員的重要的角色。美國醫療機構評鑑聯合會(JCAHO)在第34期嚴重醫療過失警訊中，報導因為給藥疏忽，將原本應由靜脈注射的癌症藥物vincristine注射到病人的脊椎，導致病人死亡或癱瘓的嚴重醫療過失。JCAHO嚴重醫療過失警訊小組的專家建議醫院應加強高警訊藥物作業管理程序，以防止類似的不幸事件。本文介紹美國南加州一個擁有多家醫院的醫療機構，依據JCAHO的建議，制訂改善高警訊藥物作業的計畫、過程、和監測方式。該醫療機構由跨院區的藥學和護理部主管共同主持一個高警訊藥物作業管理小組，制訂新的標準化作業流程。不但改善現有的作業管理程序，並且藉由各部門醫療人員的團隊合作，擬訂具體可行的新措施。該醫療機構也積極推行合作和夥伴式的管理，邀請臨床護士一同參與制訂高階層政策，因此提升了護理的能見度、領導地位和專業形象。

關鍵字

藥物安全 ； 高警訊藥物 ； 獨立雙重複核 ； 護理領導

並列摘要

Nurses play an important role in patient safety. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Sentinel Event Alert Issue 34 addressed fatal medication errors caused by administering vincristine to patients intrathecally. Experts in the JCAHO Sentinel Event Alert Group proposed changes in practice to minimize similar fatal errors. The pharmacy and nursing leaders were charged to form a high alert medication team to implement the needed policy and practice changes. To incorporate JCAHO recommendations into standardized practice throughout a multi-hospital organization and assure that it was followed consistently across all disciplines require organizational support and a carefully crafted design. This article shares the plan, process and measurement of a successful practice in the implementation of a highalert medication policy. The organizational culture of a Joint labor and management partnership empowering staff nurses in the committee elevated nursing visibility, leadership and professional pride.

並列關鍵字

Medication safety ； high-alert medications ； independent double check ； nursing leadership