護理給藥錯誤之研究

Abstract

中文摘要 本研究之目的欲瞭解目前國內護理人員給藥錯誤之種類，進而探討造成護理人員給藥錯誤之危險因素，並依據研究結果對醫院管理者提出降低給藥錯誤之策略建議。研究採橫斷式問卷調查，以46家參與研究之地區教學(含)以上醫院之護理人員為對象，調查期間為93年7月21日至93年10月27日，共發出6964份問卷，回收之有效問卷共5359份，回收率為76.95%。 本研究所使用問卷內容經過專家效度檢定，自變項包括：個人特質與專業訓練因素、工作狀況因素、與醫院作業環境因素；依變項為發生護理給藥錯誤之類別，主要是採用ASHP(1982)對給藥錯誤類型之定義，再根據Wolf(2000)及Benner (2002)研究之分類加以修正，共分為：遺漏、未授權、劑量錯、途徑錯、速率不當、劑型錯、時間不符、準備不當、病人錯、藥物錯、及頻率與醫囑不符(過快或過慢)等十種給藥錯誤類別。 研究結果：最常發生之護理給藥錯誤類型與其發生之比例為：(1)給藥時間不符(43.78%)、該給的藥漏給(43.01%)、給藥速率過快或過慢(42.31%)三種。與護理給藥錯誤之發生有顯著正相關之因素包括：工作職務、護理工作年資較淺、缺乏資深人員協助指導、工作負荷過重、工作量過大、未定期檢測給藥儀器功能與安全性、缺乏主動溝通、未遵守三讀五對、沒有標準作業流程等。 本研究根據以上結果提出以下建議：(1)重視人員之訓練與經驗之傳承，善用資深人員對資淺人員之指導與監督，使其能將寶貴經驗傳給新進人員、並給予其適時之協助與指導，使得新進人員即使在忙碌工作中仍有詢問、與提供協助的支援，應可避免錯誤的發生。 (2)重視護理人力不足的問題，只要護理人員能有充裕的時間完成工作，落實三讀五對應非難事。(3)工作環境改善，如建立藥物資訊查詢系統並定期更新。(4)提供藥物相關教育訓練。(5)改採正向態度、鼓勵通報錯誤、並對錯誤案例實施定期檢討、且針對疏失原因對護理人員及單位主管進行教育。 (關鍵字：用藥錯誤、護理給藥錯誤)

Abstract The purposes of this study are to understand the types of medication administration errors in nurses, and to explore the risk factors related to medication administration errors, as well as to bring up strategies for medication errors reduction. This study was a cross-sectional questionnaire survey which included 46 hospitals. During two-months period data collection, 5359 valid quesstionairres were obtained. The designed questionnaire included three independent variables: the individual background and professtionalism, work conditions, and environment factors. The dependent variable was defined as perceived medication administration errors which had ten categories: omission, unauthorized drugs, wrong dose, wrong route, wrong rate, wrong dosage form, wrong time, wrong preparation of a dose, wrong patien, wrong drug, more or less frequency. Three most frequent occurred error types were identified: wrong time(43.78%), omission(43.01%), and wrong rate(42.31%). Risk factors related to medication administration errors are: less work experience, professionalism, lack of teamwork, lack of communication, overworkload of nurses, not following SOP of medication administration. According to the research finding, suggestions for safe medication administration are as following:(1) To encourge the experienced nurses to help training and supervising the less experienced nurses, so medication errors could be avoided. (2) Adequate staff level is critical for medication error reduction. (3) Establish drugs inquiry information system. (4) Provide medications related education. (5) Encourage report of medication errors. (Key words: medication errors, medication admistration errors)