精神科門診注射治療之流程改善方案

Program for Outpatient Injection Therapy Process in Psychiatric Department

甘惠瑩(Hui-Ying Kan) ； 林美珍(Mei-Chen Lin) ； 陳繼鳳(Chi-Feng Chen) ； 謝燕青(Yen-Ching Hsieh) ； 甘惠玲(Hui-Ling Kan)

《高雄護理雜誌》 34卷3期 (2017/12) Pp. 48-58

https://doi.org/10.6692/KJN.201712_34(3).0005

摘要

精神科門診因病人的服藥不規律，須採取長效針劑注射治療，病人需在門診先接受針劑注射完成後才能離開單位，2014 年7 月因出現給藥錯誤事件，故單位成立小組進行給藥流程的改善。經調查發現：門診醫師開立注射單後由診間助理員交給櫃台人員，櫃台人員再轉交至護理人員，造成第二手交班；給藥三讀五對未確實；同一時段有2 位以上病人打針的因素導致給藥錯誤。經組內成員的討論與集思下，擬定對策：1.制定精神科門診針劑注射指導書(交班與注射流程)；2.制作標語，提醒三讀五對的執行；3.成立針劑照片衛教區，指導病人認識所施打的藥物，參與及為給藥安全做把關；4.針劑藥名放大與顏色區分。經由本專案的執行，不僅提升單位的給藥品質，亦達到給藥安全的目標值「針劑給藥錯誤率為0 %」。

關鍵字

用藥錯誤 ； 病人安全

並列摘要

Patients taking medication is irregular in psychiatric outpatient settings, as these outpatients must use long-term injection of therapy. They must need to leave the outpatient department after the accepted injection process is complete. In July 2014, due to the occurrence of medication errors, the outpatient unit set up a group to improve the drug administration process. Investigation found problems with medication errors, where the outpatient physician had ordered injection prescription to the clinic’s staff, who then made referral to the counter staff, who then in turn made referral to the nursing staff. “Three read and Five pairs” medication action was not being executed correctly, and at the same time, more than two patient’s injections were being dealt with. Formulated countermeasures included: 1. Development of psychiatric outpatient injection instructions (to shift the injection process); 2. Make reminder slogans for the implementation of the three read five pairs; 3. Produce photo of the injection to guide patients into knowing the drugs used; 4. Drug name enlargement of injection and color distinction. After implementation of the project, the quality of the unit was enhanced and the safe target value of administration of ＂Injection error rate is 0%＂ was achieved.

並列關鍵字

Medication error ； patient safety

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