目的：本文旨在以某醫學中心條碼給藥系統推行期間面臨給藥作業流程改變、人員工作行為不同及硬體設備擴充性不足等困境，以全面品質管理策略成功克服障礙之經驗分享，提供各醫療院所推行條碼給藥系統之參考。方法：該醫學中心透過全面品質管理方案擬定四大策略，即系統上線與人員教育訓練之整合性規畫、單軌作業稽查指標之建立、稽核制度與管控追蹤準則之制訂與給藥安全守則之擬定、系統問題及硬體設備之改善，以協助臨床護理人員熟悉系統操作程序且提高遵行率。結果：利用整合性規劃之教育訓練策略，使一般病房操作約70天即可順利完成上線進入單軌作業，另以抽查稽核指標及閾值之建立，稽核結果發現95%護理人員掃描手圈條碼遵從率高於閾值，92%藥囑簽用完成率達到閾值，顯示所擬之全面品質管理策略奏效。結論：利用條碼給藥系統執行護理給藥作業雖可提升用藥安全，但需要持續稽核追蹤，以確保護理人員能遵守標準操作程序，並期望提昇病人用藥安全，且對護理實務有所助益。

Objectives: This article reviewed the experience with bar code medication administration (BCMA) deployment and total quality management (TQM) strategy, and may serve as a reference for related healthcare institutions or agencies in implementing this information system. Methods: The medical center used TQM and four strategies: development of a plan for system implementation and continuing education, establishment of single-track operation audit indicators, writing audit and medication administration safety guidelines, and improvements in system hardware. Results: General medical and surgical wards successfully implemented BCMA and used single-track operations after an average of 70 days, while audit results showed that the TQM strategy was effective. Conclusion: The use of BCMA can enhance medication safety, but continued auditing is necessary to ensure that nursing staff comply with standard operating procedures. This change in workflow can improve both medication safety and nursing practice.