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  • 學位論文

臨床護理人員給藥錯誤及其相關因素探討

A Study on Medication Errors and related factors in Nurses

指導教授 : 周傳姜

摘要


本研究目的在探討臨床護理人員發生給藥錯誤現況及其相關因素。採橫斷式問卷調查法,研究對象為任職南部三所區域教學醫院之450位護理人員,問卷回收率90.9 %。調查所得資料以SPSS for Windows 10.0進行描述性相關統計分析。 研究結果顯示:研究對象女性佔99.3%,教育程度專科佔一半以上(66%),專業能力進階層級N1佔46.5%最多,69.3%病室有他科病患借住。在護理人員給藥錯誤方面顯示:1. 半年內自己或觀察到他人給藥錯誤類型發生次數前五位為(1) 給藥時間與醫囑不相符;(2) 該給的藥漏給;(3) 給藥速度曾被告知過快或過慢;(4) 沒有醫囑而自行給藥及(5) 給藥途徑與醫囑不相符。2. 半年內自己或觀察到他人給藥錯誤發生原因次數前五位:(1) 護理人員感疲累、體力透支;(2) 醫師手寫醫囑不易辨識;(3) 給藥前未再次核對醫囑;(4) 給藥時被事務中斷或干擾分心及(5) 給藥時未評估病患或家屬對藥物作用副作用瞭解程度。在護理給藥錯誤相關因素方面,本研究發現:1. 平均每週工作(含加班)61-70小時者易發生「給藥時間與醫囑不符」、「護理人員感疲累體力透支」及「醫師字跡潦草不易辨識」、「工作時被事務中斷干擾致分心」。2. 腫瘤病房易發生「給藥時間與醫囑不相符」「醫師手寫醫囑潦草不易辨識」;婦產科病房易發生「給藥前未再次核對醫囑」; 安寧病房易發生「給藥時被事務中斷或干擾致分心」。3. 病室有他科借住易發生「醫師手寫醫囑潦草不易辨識」、「給藥前未再次核對醫囑」。4. 新進人員被指導時間少於1個月與「給藥時間與醫囑不相符」給藥錯誤有顯著相關性。 本研究結果可供護理給藥監控及給藥系統改善之參考。

關鍵字

護理人員 給藥錯誤

並列摘要


The purpose of this study was to investigate the current status of medication errors caused by clinical nurses and correlative reasons. A cross-sectional, correctional coefficient design was used. Convenient sampling was employed to recruit 450 clinical nurses from three regional teaching hospitals in Southern Taiwan. The response rate is 90.9%. Data were filed in code and descriptive statistic analysis was conducted by applying SPSS for Windows 10.0 The research result shows: 99.3% of the research samples were female; more than half (66%) graduated from junior nursing college; 46.5% with nurse laddrer I ( N1) ; 69.3% of the wards accepted patients from different departments. The first five types of medication errors found by self or by others within half year were: (1) medication time incompatible with medical order; (2) medicine missed; (3) medication speed too fast or too slow; (4) take medicine by self without medical order; and (5) medication method incompatible with medical order. In regard to medication errors caused by nurses, the first five reasons of medication errors found by self or by others within half year were: (1) nurses feel tired and physical strength exhausted; (2) the handwritten medical order of physician is scratchy and not easy to read; (3) no double check for medical order before medication; (4) medication was interrupted by other affairs and caused distraction and (5) no evaluation on patients or their family members’ understanding about medicine side effect before medication . In the aspect of correlative reasons: 1. Nurse’s with working 61-70 hours (include overtime) weekly tends to cause "medication time incompatible with medical order", "nurse feel tired and exhausted" as well as "physician handwriting scratchy and not easy to read", "interrupted by other affairs during work and cause distraction". 2. Study as per department: oncology ward is more inclined to cause "medication time incompatible with medical order" and "physician handwritten medical order is scratchy and not easy to read"; Maternity ward room tends to cause "no double check for medical order before medication"; Hospice ward tends to cause "interrupted by other affairs and cause distraction during medication". 3. Wards lodged by patients from different departments tend to cause "physician handwritten medical order is scratchy and not easy to read" and "no double check for medical order before medication". 4. New staff with training time less than one month are significantly related to the medication error of “medication time incompatible with medical order” . This research result provides a reference for improving nurse medication supervision and medication system.

並列關鍵字

Nurse Medication Errors

參考文獻


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