建立專科護理師協助醫師開立醫囑之流程

Establishment of the prescribing procedure for a nurse practitioner as assistant to a physician

江柏逸(Po-Yi Chiang)

指導教授 ： 王明揚

國立清華大學/工學院/工業工程與工程管理學系/碩士(2019年)

摘要

用藥過程是從醫生開立與輸入處方，經過藥師調劑，到最後護理人員給予病患藥物的流程。其中牽涉的人員眾多而且程序複雜，任何環節都有可能出現漏洞。根據2016年病人安全通報系統的結果顯示藥物事件佔通報事件類別中最多比例，並且主要發生在醫囑開立與輸入階段。然而過去開立處方錯誤的研究大多著重在電腦化醫囑系統的介面改善，較少研究探討流程上的問題。此外住院病人的藥物處方主要是由專科護理師隨同醫師查房，依據醫師口頭指示，協助開立與輸入處方至電腦化醫囑系統中，最後再由醫師確認處方。因此本研究將探討專科護理師在協助醫師開立住院病人處方的流程，並為其建立預立標準作業程序，以期降低藥物異常事件。
本研究共分為三個階段，第一階段針對現有臨床上的流程進行探討，並與5位專家透過醫療照護失效模式與效應分析結合人為因素分析與歸類系統，找出流程中的失效模式與其背後的根本原因。第二階段使用以病人安全為目標且應用於流程設計上的人因工程原則，設計出符合專科護理師查房時使用之查房表格與規範數個覆誦步驟於預立標準作業程序中。第三階段透過模擬任務實驗以及四個評估指標，滿意度、心理工作負荷、正確度、操作時間，來驗證預立標準作業程序改善之成效。研究結果雖然顯示心理工作負荷與操作時間未達顯著，但是在滿意度與正確度皆顯著，代表預立標準作業程序確實有效避免錯誤與符合人員使用。
本研究期望藉由探討所得到的失效模式、根本原因結果以及預立標準作業程序能夠做為醫療院所之參考依據，並消弭藥物異常事件之發生，以促進病人安全之目標。

關鍵字

住院病人處方開立流程 ； 醫療照護失效模式與效應分析 ； 人為因素分析與歸類系統 ； 專科護理師

並列摘要

Medication-use process, which contains prescribing, dispensing and administration, involves in multidisciplinary professional and complexity. Any steps in the process could be result in error. According to the 2016 annual report of Taiwan patient safety system, it indicated adverse drug event accounted for the most percentage of all categories, and also it mostly occurred in the prescribing stage. However, previous researches about prescribing error focused on improving interface of computerized physician order system and less than on investigating the problems in the process. In addition, inpatient prescribing procedure is majorly assisted by nurse practitioner which start with rounding, helping with prescribing and typing in prescription and confirming by the physician. Therefore, this study would investigate the prescribing procedure for a nurse practitioner as assistant to a physician, and establish preliminary standard operating procedure in order to reduce numbers of adverse drug events.
The study consist of three stages. The first stage is to examine the existing clinical process and cooperate with five experts in order to identify failure modes and root causes by integrating healthcare failure mode and effect analysis with human factors analysis and classification system. The second stage is to establish preliminary standard operating procedure by using human factors principles for patient safety. The study design ward round template for nurse practitioner and add several readback steps in preliminary standard operating procedure. In the third stage, preliminary standard operating procedures was validated by using simulated- task experiment and four outcome measures of satisfaction, mental workload, accuracy and operating time. The result shows mental workload and operating time were not significantly different with each other. But, satisfaction and accuracy have significant difference. It is represented that preliminary standard operating procedure could effectively prevent errors and be more suitable for nurse practitioner.
It is expected that the results of failure modes, root causes and preliminary standard operating procedure could be used as reference for medical institutions in order to eliminate occurrence of adverse drug event and improve the patient safety.

並列關鍵字

Inpatient prescribing ； Healthcare failure mode and effect analysis ； Human factors analysis and classification system ； Nurse practitioner

參考文獻

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