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題名:護理人員給藥錯誤現況及其相關因素之探討
書刊名:醫務管理期刊
作者:謝生蘭劉芹芳 引用關係李金德 引用關係林秀鳳張肇松
作者(外文):Shieh, Sheng-lanLiu, Chin-fangLee, King-tehLin, Shiu-fengChang, Chao-sung
出版日期:2009
卷期:10:1
頁次:頁48-62
主題關鍵詞:護理人員給藥錯誤異常事件通報NurseMedication errorsAdverse event reporting
原始連結:連回原系統網址new window
相關次數:
  • 被引用次數被引用次數:期刊(6) 博士論文(0) 專書(0) 專書論文(0)
  • 排除自我引用排除自我引用:6
  • 共同引用共同引用:13
  • 點閱點閱:98
目的:本研究旨在探討南部某醫學中心護理人員給藥錯誤情形及其影響之相關因素。 方法:本研究爲回溯性相關研究。研究樣本爲2003年8月至2006年7月護理人員每月主動通報之給藥錯誤異常事件共317人次,其中有229人發生給藥錯誤。 結果:研究結果顯示護理人員給藥錯誤率爲8.78%,平均錯誤次數爲1.38±0.77次,最高爲5次。以年齡層在20-24歲、三個月內試用期及NO層級的新進人員最多。給藥錯誤率呈現不穩定狀態與人力不足及新進人員大幅增加可能有關。錯誤原因以執行「三讀五對」過程中出錯比率最高,其次爲因藥物外型或藥名相似、多種劑量等辨識不足。在給藥辨識項目以藥物的錯誤最多,而藥物類型以針劑類抗生素的錯誤最多,在白班錯誤比率高於其他班別。給錯藥對病人的傷害,經嚴重度分級評估,受到中度以上傷害需持續治療者有5.36%。護理人員的年資、科別、進階層級及班別與錯誤次數有顯著差異。外科病房及N進階層級人員是影響給藥錯誤之預測因子。 結論:護理人員給藥時應確實遵循「三讀五對」原則。護理主管應加號新進人員給藥標準作業執行及對藥物認識,針對錯誤頻率較高的單位及容易出錯人員列爲優先輔導對象。醫院應致力系統方面等問題之改善,以降低護理人員給藥錯誤風險。
Objective: This study aimed to investigate the status of and factors related to the occurrence of nursing medication errors (NMEs) in a medical center in southern Taiwan. Methods: A total of 317 adverse events reported voluntarily by 229 nurses from August 2003 to July 2006 at this medical center were analyzed. Descriptive and correlation analysis was performed to identify factors associated with the occurrence of NMEs. Results: The NME occurrence rate was 8.78%. The mean±SD frequency of NMEs for the reporting nurses was 1.38±0.77 times, with a maximum frequency of 5 times. Nurses who were aged 20 to 24 years, who were still completing the 3-month probation period, and who were at the N0 stage of the clinical ladder had higher NME rates than the other nurses. The NME rate reported to the hospital varied from month to month, in association with nurse workforce insufficiency and surges of recruitment of new staff during some periods. The most frequent cause of NMEs was lack of compliance with the ”three-reads, five-rights” process, followed by confusion of drugs with similar names and appearances. Among drug types, antibiotics, especially those given in injection form, were most commonly involved in errors. Nurses who worked the day shift had a higher NME rate than those who worked other shifts. Regarding the consequences of medication errors, 5.36% of patients suffered from at least a moderate degree of injury for which they needed treatment. The nurses' number of years of experience, position on the clinical ladder, units, and shifts were significantly correlated with NME frequency. Working in the surgical ward and being on the N clinical ladder were significant independent variables predicting the frequency of NMEs. Conclusion: Based on our results, we suggest that hospital nurses strictly follow the ”three-reads, five-rights” process when administering medicine to patients. Improving new nurses’ drug-identification ability and compliance with standard operating procedure is an important issue for the clinical nursing administration.
期刊論文
1.蔡淑鳳、王秀紅(20070200)。臺灣護理教育之自省與前瞻--護理人力政策面。護理雜誌,54(1),5-10。new window  延伸查詢new window
2.石崇良、侯勝茂、薛亞聖、鍾國彪、蘇喜、廖熏香(20050100)。異常事件通報系統與通報障礙。臺灣醫學,9(1),63-70。  延伸查詢new window
3.Aiken, Linda H.、Clarke, Sean P.、Sloane, Douglas M.、Sochalski, Julie、Silber, Jeffrey H.(2002)。Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction。Journal of the American Medical Association,288(16),1987-1993。  new window
4.Stratton, K. M.、Blegen, M. A.、Pepper, G.、Vaughn, T.(2004)。Reporting of medication errors by pediatric nurses。Journal of Pediatric Nursing,19(6),385-392。  new window
研究報告
1.薛亞聖、石崇良、廖薰香、羅恆廉、曾慧萍、張穎貞(2003)。建立安全的醫療環境-病人安全建構之規劃。醫院評鑑暨醫療品質醫策進會。  延伸查詢new window
其他
1.行政院衛生署(2008)。97-98病人安全年度目標。  延伸查詢new window
2.財團法人醫院評鑑曁醫療品質策進會(2007)。新制醫院評鑑曁新制教學醫院評鑑基準及說明。  延伸查詢new window
3.Barclay, L.(2002)。Hospitals make medication errors in 19% of doses。  new window
4.台灣醫療改革促進會(2008)。95年醫療糾紛個案主訴統計分析表。  延伸查詢new window
5.鄭聰明(2007)。醫療事故的法律觀。  延伸查詢new window
6.Vincent,C.(2003)。Patient safety: Under-standing and responding to adverse events。  new window
7.林麗珍、陳淑嬌、李麗雲等(2007)。護理人員對給藥錯誤原因看法之初探。  延伸查詢new window
8.林秋芬、陳玉枝、張文英、高靖秋、林月桂、盧美秀(2005)。醫療照護疏失原因之探討。  延伸查詢new window
9.O’Shea, E.(1999)。Review factors contributing to medication error: A literature review。  new window
10.Krichbaum K, Diemert C, Jacox L, & Jones A.(2007)。Complexity compression: Nurse under fire。  new window
11.Elnou AA, Ellahham NH, & Oassa HI.(2007)。Raising the awareness of inpatient nursing staff about medication errors。  new window
12.台灣醫務管理學會(2008)。住院指標同級醫院比較報表。  延伸查詢new window
13.Sanghera, IS, Franklin BD, & Dhillon S.(2007)。The attitudes and beliefs of healthcare professionals on the causes and reporting of medication errors in UK intensive care unit。  new window
14.Yang K.-P.(2003)。Relationships between nurse staffing and patient outcomes。  new window
15.Backer, K. N.(2000)。The effects of an experiment medication system on medication errors and costs。  new window
16.葉冠欒、廖慧燕、黃光永(2007)。改善藥物標示與包裝促進用藥安全。  延伸查詢new window
17.Grandell-Niemi, H., Hupli, M.,Leino-Kilpi, H., Puukka, P.(2002)。Medication calculation skills of nurses in Finland。  new window
 
 
 
 
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