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題 名 | 降低門診化學治療處方電腦輸入錯誤率專案=Reduce Outpatient Chemotherapy Prescriptions Input Error |
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作 者 | 李靜枝; 劉麗珒; 張嘉蘋; | 書刊名 | 高雄護理雜誌 |
卷 期 | 30:1 2013.04[民102.04] |
頁 次 | 頁37-50 |
分類號 | 419.38 |
關鍵詞 | 化學治療; 病人安全; 給藥錯誤; Chemical treatment; Patient safety; Medication errors; |
語 文 | 中文(Chinese) |
中文摘要 | 化學藥品為具毒性的高危險性的藥物,一旦發生給藥錯誤,常危害到病人生命安全及引起醫療糾紛。本院門診由於作業方式特殊,化學治療處方電腦輸入是由跟診人員執行,統計錯誤率有12.78%,因而引發之給藥錯誤率有0.1%。經討論分析,發現引起處方輸入錯誤的原因為跟診人員經驗不足、跟診人員電腦處方列印前未確實核對內容、化療處方開立格式不一致、資訊系統設計不良、醫囑開立不清楚。故而本案目的在將門診化學處方電腦輸入錯誤率降低至1%以下。對此提出解決方法為:資訊系統建立及標準化,並列印給藥單代替抄錄之給藥單、統一化療處方開立格式、舉辦相關教育訓練、宣導及定期回饋。方案實施後(一)建立門診化學治療資訊系統及處方開立標準(二)改善診間電腦化療藥物輸入畫面及簡化診間人員電腦輸入處方步驟(三)門診化學治療處方電腦輸入錯誤率由原本12.78%下降至0.84%,給藥錯誤率為0;因專案之推展,促成門診化學治療藥物全程調配,增加工作環境之安全性,且無因而引發之給藥錯誤事件發生。 |
英文摘要 | The purpose of this case was outpatient prescription computer input error rate of chemical reduction to less than 1%, and no medication errors. Toxic chemicals as high-risk drugs in the event of medication errors, often endanger the lives of patients and lead to medical disputes. As special out-patient hospital practices, chemical treatment regimen computer input error rate was at 12.78%. Discussion and analysis found that the reasons for input prescription errors was caused by lack of experience of clinical staff, as staff doing the computer check did not prescribe the content before printing, and the chemotherapy order entry form was not standardized, presenting lack of information system design. A solution to this is: the establishment and standardization of information systems to organize relevant training, information supporting operating system updates, public awareness, and regular feedback. After successful implementation: (a) outpatient chemotherapy prescriptions computer input error rate dropped to 0.84%, no medication errors occurred; (b) improvement of the clinic, and computer information systems simplifying data entry of personnel prescription consultation step was demonstrated; (c) a new clinical chemotherapy prescribing information systems and standards was established; and (d) promotion of full deployment of outpatient chemotherapy drugs met the accreditation standards. |
本系統中英文摘要資訊取自各篇刊載內容。