提升某外科病房護理人員給藥步驟正確率

Improve the Accuracy of Drug Administration Steps for Nursing Staff in a Surgical Ward

10.6647/CN.202409_31(3).0009

許雅涵(Ya-han Hsu)；陳韋安(Wei-An Chen)；林意雯(Yi-Wen Lin)；周敏怡(Min-I Chou)

給藥正確率 ； 遊戲式學習 ； 改善專案 ； accuracy of medication ； game-based learning ； project improve

彰化護理

31卷3期（2024 / 09 / 01）

60 - 75

繁體中文;英文

本文主旨為提升護理師給藥步驟執行正確率，回溯本單位於2018年至2019年共20件給藥異常，在給藥執行中，護理人員是病人用藥把關者，因臨床上發現人員執行給藥步驟正確率僅75.1%，故引發專案動機，護理人員給藥步驟正確率低之導因為：工作導向輕忽給藥行為、未依標準作業流程執行給藥技術、部分人員對於操作不熟悉，而沒有善用護理公用手機、備藥過程中斷後未能重新核藥。改善策略：小組長三班抽檢人員給藥技術、內化給藥行為－設計「就藥這樣玩」教學遊戲、每日運用單位廣播系統通知即將開始發藥的時間、利用公用手機操作方式流程圖宣導人員利用手機轉接功能接聽電話及紅鈴、小組長隨身配戴公用手機及人員應適時求援等五項，達成護理師給藥步驟執行正確率提升至100%，進而提升病人安全照護品質。

The purpose of this paper is to improve the correct rate of drug administration steps for nursing staff. Looking back at the unit from 2018 to 2019, a total of 20 abnormal drug administration cases were found. In the process of implementing the drug delivery technology, the nurses are the gatekeepers of the patient's medication. It was found that the correct rate of the personnel executing the drug delivery steps was only 75.1%, so the motivation of the project was triggered. The reasons for the low accuracy of the drug administration steps of the nursing staff are: work-oriented neglect of drug administration behavior, failure to perform drug administration techniques in accordance with standard operating procedures, some nursing staff are not familiar with the operation methods and do not make good use of public mobile phones for care, and failure to re-check the drugs after the drug preparation process is interrupted. Improvement methods: the team leader checks the drug administration technology of the staff every day, internalize the drug administration behavior - design the teaching game of "playing like the drug", use the unit's broadcast system every day to notify the time when medicine is about to be distributed,and use the public mobile phone to operate the flow chart Propagandists use the mobile phone transfer function to answer calls and red bells, team leaders wear public mobile phones, and personnel should seek help in a timely manner, so that the accuracy rate of nursing staff's drug administration steps has been increased to 100%, thereby improving the quality of patient care.

1. 李佳蓉、蘇蕙琪、陳寶如、潘玟玲、蕭棋蓮、胡慧蘭、任秀如(2019)‧遊戲式創新教學於臨床新進護理人員高警訊藥物訓練之學習成效‧新臺北護理期刊，21(2)1-11。https://doi.org/10.6540/NTJN.201909_21(2).0001
   連結：
2. 張憶茹、梁維麗、李佳蓉、魏麗香、徐慧雯、葉蕙芳(2017)‧導入客觀性結構式臨床測驗降低新進護理人員給藥錯誤發生率‧健康科技期刊，4(1)，65-85。https://doi.org/10.6979/TJHS.201707_4(1).0005
   連結：
3. 游惠珠、陳映蓉、吳如琇、何蕴芳(2019)‧跨專業環環相扣守護安全用藥—以住院藥品管理為例‧護理雜誌，66(4)，7-13。https://doi.org/10.6224/JN.201908_66(4).02
   連結：
4. 蕭仁傑、劉宣谷(2018)‧以遊戲式教學進行金融教育對高低數學學習成就學童金融知識提升之影響‧臺北市立大學學報教育類49(2)，33-51。https://doi.org/10.6336/JUTEE.201812_49(2).0002
   連結：
5. Khalil, H., & Lee, S. (2018). Medication safety challenges in primary care-Nurses' perspective. Journal of Clinical Nursing,27(9-10), 2072-2082. http://doi. org/10.1111/ jocn.14353
   連結：
6. 洪玉玲、許家蓁(2017)‧提升加護病房護理人員執行給藥之正確率‧若瑟醫護雜誌，11(1)，76-89。
7. 黃亭鳳、陳金琳、曾鳳美、梁露珍、莊孟蓉(2018)‧降低外科加護病房護理師執行條碼給藥錯誤發生率之改善專案‧醫院雙月刊，51(3)，1-12。
8. 衛生福利部台灣病人安全資訊網（2020，11月18日）‧台灣病人安全通報系統2019年年報。https://www.patientsafety.mohw.gov.tw/Content/Downloads/List01.aspx?SiteID=1&MmmID=621273303702500244
9. National Coordinating Council for Medication Error Reporting and Prevention. (2020). About Medication Errors. https://wwwnccmerp. org/about-medication-errors