影響護理人員給藥錯誤通報障礙之文獻探討

Exploring Nurses' Barriers and Related Factors in Reporting Medication Administration Errors

雍海鵬(Hai-Peng Yung) ； 唐福瑩(Fu-In Tang)

《健康與建築雜誌》 1卷2期 (2014/02) Pp. 76-81

https://doi.org/10.6299/JHA.2014.1.2.R7.76

摘要

用藥安全是國際間共同關注之全球性議題；也是病人安全及醫療照護品質最重要的指標，而其中最重要的目的就是要減少給藥錯誤的發生。藥物疏失是最主要的醫療錯誤，而給藥錯誤是最主要之藥物疏失。綜合文獻護理人員給藥錯誤之原因可歸類為人為因素和系統因素，給藥錯誤最常發生之班別在白班；主要錯誤類型以藥物錯誤及劑量錯誤最為常見。研究指出大於38%的藥物疏失是發生在護理人員給藥階段；然而護理人員估計只有25%～63%的給藥錯誤被通報。因此，了解護理人員給藥錯誤未通報的障礙相關因素是增加給藥安全的第一步。文獻探討指出：護理人員主要之通報障礙是害怕通報後之結果、對通報流程之認知不足及主管負面態度的影響；護理人員給藥錯誤通報障礙會因年齡、教育程度、職稱、年資、級階、通報經驗之不同而有所差異。雖然目前大力提倡非懲罰性通報，但護理人員對通報仍有害怕等不安全感。因此增加護理人員對通報之認知與減少通報之障礙；才能全面進行通報文化之改善。

關鍵字

護理人員 ； 給藥錯誤 ； 通報 ； 通報障礙

並列摘要

Medication safety is a major concern worldwide and global issue for the quality and safety of patient care. Reducing medication administration error incidents is a critical medication safety issue. Medication errors are the most common types of medical errors, Medication Administration Errors (MAEs) accounted for the major part of all medication errors. Through review of related literatures: the most common errors had occurred the day shift and involved wrong dose and wrong drug. Medication errors have been attributed to a variety of individual and system factors. Research statistics showed: 38% above of medication errors happened during the administration stage. However, nurses estimated that only 25% to 63% of MAEs were actually reported. Understanding of nurses' barriers in reporting MAEs and related factors is the initial step to strengthen medication safety. These factors are considered to be barriers that hinder nurses in reporting MAEs. The major perceived barriers were fear of the consequences of reporting, lack of perceptions in reporting and the negative impact by the administrator's attitudes. The nurses' barriers in reporting MAEs differed by age, education background, job position, working experience, reporting experience, nursing grade. Nurses still have fear and feel insecure even the administration encourages reporting without punishment. Thus, it is advisable to strengthen the perceptions of reporting and decrease the nurses' barriers in reporting MAEs for the overall improvement in MAEs reporting culture.

並列關鍵字

Nurse ； Medication Administration Errors ； Reporting ； Reporting Barriers

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