護理人員對給藥錯誤認知之探討

A Study of Nurse Perceptions of Medication Errors

許慧玉(Hui-Yu Hsu)

指導教授 ： 陳彰惠

高雄醫學大學/護理學院/護理學系研究所/碩士(2005年)

摘要

本研究目的在探討護理人員認為造成給藥錯誤的原因、分類與通報的知覺及通報給藥錯誤的觀感。採結構式問卷調查法，以「護理人員給藥錯誤認知量表」收集南部某醫學中心及某區域教學醫院1529位護理人員，共得有效問卷1352 份，有效回收率91.91%。研究資料以SPSS
for Window 10.0 版設計套裝軟體統計分析。
研究結果發現:(1)護理人員認為造成給藥錯誤的原因，前三位排名分別為兩種相似藥名及外型的藥物易發生混淆，醫師手寫醫囑不易辨識或不清楚，及醫師開立錯誤劑量之處方。(2)護理人員認為所有給藥錯誤事件中，估計64%會完成異常事件報告並向護理主管通報。(3)護理人員回憶護理生涯中之平均給藥錯誤次數為2 次。(4)護理人員對給藥錯誤分類與通報的知覺較無一致的看法，未通報給藥錯誤的主要原因包括懼怕護理主管的反應和害怕工作同仁的反應。(5)護理人員對給藥錯誤的認知與基本屬性的年齡、進階職級、執業年資、工作科別與給藥錯誤次數達多項顯著差異。
據本研究結果建議護理行政主管應重視護理人員認為造成給藥錯誤的原因、分類與通報的知覺及通報給藥錯誤的觀感，減少藥物處理錯誤的措施應包含: (1)推行醫囑電腦化及自動化電腦藥物管理系統以取代容易出錯的人工作業系統，(2)透過新穎具成效的藥物管理監測系統改善用藥安全，及(3)建立以非處罰及匿名的異常事件通報系統，鼓勵同仁落實通報並從中學習以降低給藥錯誤的發生，營造以病人安全為中心之文化。

關鍵字

護理人員 ； 異常事件通報 ； 給藥錯誤

並列摘要

The purpose of this study was to explore the nurse perceptionsabout medication errors in Southern Taiwan. Structured questionnaireswere translated and utilized to collect data. This cross-sectional study wasconducted with convenience sample of 1529 nurses recruited from a medical center and a regional hospital. A total of 1352 nurses (91.91%)nurses completed the questionnaires.
The findings showed that: (1) Possible causes of medication errorsranked top three were two drugs with similar names, illegible handwritingand physician prescribing the wrong dose. (2) They estimated that 64% ofall drugs errors were reported to the nurse manager by the completion of an incident report. (3)They recalled 2 medication errors in
average making over the course of their career. (4) There was no agreement in classifying and reporting of medication errors, and reasons for notreporting include fear of
manager and peer reactions. (5) The importantrelated factors of nurses perceptions of medication errors included age,clinical ladder, years of RN practice, work settings,
and frequency ofmedication errors.
The findings of this study can be used in programs designed to promote medication errors recognition, also provide the nursingadministrator pay attention to the nurse perceptions of medication errorsissue. It is recommended: (1) Follow out the computerized physicianorder entry (CPOE) and automated dispensing machines (ADMS) to replace manual work. (2)Facilitate emerging technologies as potential mechanisms for reducing medication errors. (3) Establish a blame-free and anonymous incident reporting systems, to urge reporting and to diminish medication errors.

並列關鍵字

medication errors ； incident reporting ； nurse

參考文獻

一、中文部分

方麗萍（2002）．安全的藥物治療過程．領導護理，5 (1)，86+96。

石崇良、侯勝茂、薛亞聖、鍾國彪、蘇喜、廖熏香（2005） ．異常事件通報系統與通報障礙．台灣醫學，9(1)，63-70。

行政院衛生署 (2002,12月10日)．取自http://www.doh.gov.tw/

吳惠美、施李碧玉(2004)．藥物交互作用之發生率及發生機轉．北市醫學雜誌，1(3)，372-379。