降低生酮飲食治療病童誤用含醣藥品之發生率專案

本專案旨在降低生酮飲食治療病童誤用含醣藥品之發生率。生酮飲食係維持體內高濃度酮體，穩定神經以控制癲癇發作，若誤給予含醣藥品，導致酮體消失，癲癇發作頻繁，影響控制成效。經現況分析確定主要問題為：醫護人員對生酮用藥認知不足；照顧者輪替或就醫時未主動告知，及家屬未接受用藥衛教；未建置生酮用藥警示及查核機制。專案執行期間自2014年12月01日至2015年10月30日，擬定改善方案：包括舉辦醫護人員教育訓練、錄製用藥指導光碟、建置含醣用藥處方提示及用藥提示標語，與修訂用藥指導流程及稽核制度。經專案實施後，病童誤用含醣藥品之發生率可由15.1%降至0%；醫護人員對生酮用藥認知正確率由66.7%提升至100%，照顧者用藥知識正確率由40.7%提升至85.3%，皆達專案目的，顯示可透過資訊化系統管制及多元標示，減少人為疏失，提升病人用藥安全。

關鍵字

生酮飲食治療；含醣藥品；病童

並列摘要

The objective of this project is to reduce the mistake rate of carbohydrate-contented medication in child patients with ketogenic diet therapy. Ketogenic diet is an effective therapy for controlling seizures in patients with refractory epilepsy. However, mistaking carbohydrate-contented medicine would lead to disappearance of serum ketone body which results in break-through seizures and prolonged hospitalization. The possible reasons of mistaking carbohydrate-contented medicine include medical staffs having inappropriate nursery knowledge of medication safety on ketogenic diet, the health givers without informing medical staffs that patients are receiving ketogenic diet therapy, the health givers not educated with medical safety for ketogenic diet, and medication safety surveillance system not established for patients with ketogenic diet therapy. The project execution was conducted from December 1, 2014 to October 30, 2015. To decrease error rate of carbohydrate-contented suspension usage in patients with ketogenic diet therapy, we developed improvement strategies as follows. First, we organized medical staffs educational programs. We made video CD to deliver concepts of medication safety surveillance on ketogenic diet. We designed prompt slogan for medication safety. We set up medication guidance and surveillance system for medication safety. After the implementation, the mistake rate of carbohydrate-contented medicine decreased from 15.1% to 0%. The nursery knowledge of medication safety on ketogenic diet increased from 66.7% to 100%. The medication safety awareness increased from 40.7% to 85.3 %. We provided the evidence that multidisciplinary- assisted system would decrease artificial errors and improve the safety of medicine.