本單位為兒童加護病房，因靜脈給藥錯誤，造成病童生命徵象不穩。經專案小組進行靜脈給藥查檢，發現靜脈給藥不正確率為3.7%，經訪談、歸納，確立問題為：護理人員藥物計算能力不佳、缺乏剩藥儲存標準及剩藥標示貼紙、護理人員未落實雙人核對、手抄藥物劑量耗時且易抄錯、護理人員憑經驗稀釋藥物與剩藥保存。藉由制定「常用藥物使用指引」、舉辦靜脈注射藥物教育訓練、設計並印製剩藥標示貼紙、新增給藥紀錄單藥物劑量顯示、建置醫囑系統自動換算藥物抽取劑量、訂定雙人藥物核對流程等。實行改善措施後，護理人員靜脈給藥不正確率由3.7%下降為0%，且在一年半的追蹤期內，給藥錯誤發生件數為0件。專案推動確實提升靜脈給藥的正確性，有效為住院病童用藥安全把關。

The intravenous drug dosage error resulting in unstable vital signs in one child was found in our PICU (Pediatric Intensive Care Unit). We analyzed data from the intravenous medication checklist and found that the rate of incorrect intravenous administration was 3.7%. After conducting interviews and summarizing the interview results, we concluded the following causes: the nurses possessed inadequate ability to determine the correct medicine dose; standards for storing leftover medicine were not established; leftover medicines were improperly labeled, doses were not double-checked by another nurse; the time pressure of keeping dosage records leading to mistakes occurring easily; and the nurses diluted drugs and stored leftover medicine according to their experience only. The aim of this project was to decrease incorrect intravenous administration to 0%. Strategies of this project included completing a user guide for common drugs, providing nurse's continuous educational program on intravenously administering drugs, designing stickers for labeling leftover medicine, adding medicine doses on the medicine administration record, establishing computerized order management system for automatically calculating the appropriate medicine dose, and developing double-checking procedure for intravenous administration. After this project, incorrect intravenous administration rate decreased to 0% and no adverse medication event occurred in nearly one and half year. The result indicated the intervention of this project can increase accuracy of intravenous drug infusion and effectively maintain drug safety for child inpatients.