臺灣博碩士論文加值系統

本研究目的主要是探討機構用藥安全政策對護理給藥錯誤事件通報趨勢及嚴重度之影響，以及用藥安全政策介入前後護理給藥錯誤事件特性和其因素之差異。採評價性研究，以立意取樣方式收集2004年1月至2006年12月連續三年共711件護理給藥錯誤事件報告進行統計分析，另邀請13位護理人員及9位護理主管進行30-40’焦點團體訪談。研究結果發現：整體通報件數以內科系單位260件最高（36.6％），發生班別則以小夜班356件
（50.1％）為大宗，通報結果類別以漏給藥205件（28.8％）為最高、未授權170件（23.9％）次之，再其次為劑量錯誤168件（23.6％）、時間錯誤72件、（10.1％）、藥物錯誤26件（3.7％）；開立用藥電腦處方政策介入後，對通報『未授權錯誤』比率逐年下降，可能與減少因開立醫囑時間差所致之停用藥物卻仍將藥物投與病患相關。輸液幫浦雙人核對加強輸液裝置及靜脈注射使用安全政策介入後，對『劑量錯誤』呈現通報比率下降（由29.8％降至18.0％），而『流速錯誤』則呈現通報比率上升（2.4％上升至5.2％），錯誤嚴重度分類E(含)等級4以上通報比率由4.0％下降至1.2％，推論與護理部積極提升護理人員病人安全意識與鼓勵異常事件通報及輸液幫浦雙人核對加強輸液裝置及靜脈注射使用安全政策有關，使得相關通報類別所致之嚴重度均呈現下降趨勢。另經訪談得知：生手缺乏經驗判斷、臨床工作複雜度高與作業途中干擾、未依標準作業規範執行業務等，都是護理人員容易造成給藥錯誤的因素。本研究結果可提供醫院管理者與護理行政主管在臨床病患用藥安全政策擬定與護理人員教育訓練及工作排班等重要參考。

The purpose of this study was to identify how safety policy of medication administration affects the trend of using reporting system for medication errors, and the severity of medication errors in one hospital. The characteristics of medication errors and related factors were compared pre and post interventions of safety policy of medication administration. Evaluation research was used for this study. All the reported events of administration error were collected and reviewed. A total of 711 medication administration error events from January, 2004 to December, 2006 were reviewed. In addition, a 30-40 minutes focus group, which consisted of 13 nurses and 9 nursing managers, was conducted to verify the data. Results of the study revealed that the clinical physicians order entry policy intervention, to inform the unauthorized drug error declining ratio may be related to reduce the time lag caused by the drugs are still out of drugs and patient-related stagement. Double check the infusion pump and intravenous infusion device to enhance the use of security policy intervention, the right dose of the error reporting rate showed decline (from 29.8% down to 18.0%), whereas the velocity error rising rate of the present communication (2.4% rising to 5.2%), an error severity classification E (inclusive) Level 4 or above reporting rate from 4.0% to 1.2%, the inference with the Nursing Department to actively enhance patient safety awareness and to encourage nurses unusual incident reporting and double check the infusion pump to enhance the use of intravenous infusion devices and related security policies, making the relevant categories due to the severity of communication showed a declining trend, post intervention. Medical units (36.6%) had higher tendnecy to report medciation errors than other setting both pre and post interventions. Most cases were reported in the evening shift (50.1%) . Omission of medications 28.8% was the most frequently identified incidence, followed by23.9% cases of unauthorized prescriptions, 23.6% cases of wrong doses, 10.1% cases of wrong time, and 3.7% cases of wrong medications. The above information has not yet reached by the statistical significant difference, but the clinical significance remained. Results of the interview data showed three possible reasons for medication administration error, were lack of experience to judge the clinical condition, complicated work, interruption of operational procedure, and non adherence to medication administration standards. Results of the study are useful for hospital and nursing administrators’ decision making for safety policy of medication administration continuing education, and shift allocation.

致謝 ……………………………………………………………………………………… Ⅰ
中文摘要 ………………………………………………………………………………… Ⅱ
英文摘要 ………………………………………………………………………………… Ⅲ
目錄 ……………………………………………………………………………………… Ⅳ
圖表目錄 ………………………………………………………………………………… Ⅵ
第一章 緒論…………………………………………………………………………… 1
第一節 研究背景及動機………………………………………………………… 1
第二節 研究目的………………………………………………………………… 3
第三節 研究假設………………………………………………………………… 3
第二章 文獻查證……………………………………………………………………… 4
第一節 病人安全相關政策……………………………………………………… 4
第二節 用藥安全的重要性與目的……………………………………………… 6
第三節 一般用藥流程…………………………………………………………… 7
第四節 用藥錯誤之定義………………………………………………………… 8
第五節 護理給藥錯誤之定義…………………………………………………… 9
第六節 護理給藥錯誤之危險性因素…………………………………………… 10
第七節 護理給藥錯誤相關性研究……………………………………………… 12
第八節 文獻總結………………………………………………………………… 12
第九節 概念架構………………………………………………………………… 14
第三章 研究方法……………………………………………………………………… 15
第一節 研究架構………………………………………………………………… 15
第二節 研究設計………………………………………………………………… 16
第三節 造成護理給藥錯誤因素及其操作型定義……………………………… 17
第四節 機構用藥安全政策及其操作型定義…………………………………… 18
第五節 護理給藥錯誤事件及其操作型定義…………………………………… 19
第六節 研究對象與場所………………………………………………………… 24
第七節 研究工具………………………………………………………………… 28
第八節 資料收集………………………………………………………………… 30
第九節 研究對象權益保護……………………………………………………… 32
第十節 資料分析與統計方法…………………………………………………… 33
第四章 研究結果……………………………………………………………………… 34
第一節 護理人員基本資料特性描述…………………………………………… 34
第二節 病房工作任務與環境特性差異分析…………………………………… 37
第三節 護理給藥錯誤事件通報趨勢與類別差異分析………………………… 41
第四節 實施用藥安全政策後，護理給藥錯誤事件嚴重度與類別差異分析… 45
第五節 實施用藥安全政策後，護理給藥錯誤事件類別差異分析…………… 52
第六節 焦點團體訪談結果分析………………………………………………… 59
第五章 討論、總結與建議…………………………………………………………… 64
第一章 討論……………………………………………………………………… 64
第二章 結論……………………………………………………………………… 66
第三章 研究結果的應用………………………………………………………… 67
第四章 研究限制與建議………………………………………………………… 68
參考文獻
中文部份
英文部份 69
69
附件一：護理給藥錯誤事件調查表
附件二：護理給藥錯誤事件調查表（修訂版）
附件三：「護理給藥錯誤事件」質性訪談說明與受訪者同意書
附件四：「護理給藥錯誤事件」質性訪談大綱
附件五：「護理給藥錯誤事件」質性訪談原始訪談記錄

（一）中文參考資料
高紀惠、余玉眉. (1971). 醫囑與護理紀錄間一致性的調查. 護理雜誌, 18(2), 51-58.
張秉宜. (2004). 護理給藥錯誤之研究
未發表之碩士論文，台北：臺灣大學醫療機構管理研究所。
莊美華, 林俊龍, 王昱豐, 曹汶龍, & 梁育彰. (2003). 醫療機構用藥疏失之探討. 慈濟醫學, 15(4), 247-258.
陳玉枝. (2004). 從護理照護層面談病人安全. 台灣醫學, 8(4), 528-534.
黃瑞蘭. (2003). 住院病患給藥安全調查以---某區域醫院為例
未發表之碩士論文，高雄：高雄醫學大學公共衛生學研究所。.
蕭信英. (1974). 住院病人服用口服藥情況之調查. 護理雜誌, 21(3), 1-6.

（二）英文參考文獻
Abood, R. (1996). Errors in pharmacy practice. US Pharm, 21, 122-132.
American Society of Hospital Pharmacy, A. (1982). ASHP standard definition of a medication error. American Journal of Hospital Pharmacy, 39, 321.
Bates DW, C. D., Laird NM, Nan M, et al. . (1995). Incidence of Adverse Drug Events and Potential Adverse Drug Events : Implications for Prevention. JAMA
274, 29-34.
Brennan, T. A., Leape, L.L., Laird, N.M., et al. . (1991). Incidence of adverse events and negligence in hospitalized patients: Results of the Harvard Medical Practice Study I. . New England Journal of Mededicine, 324(6), 370-376.
Brown, M. (2001). Managing Medication Errors by Design. Critical Care Nursing Quarterly, 24(3), 77-97.
Gladstone, J. (1995). Drug administration errors: a study into the factors underlying the occurrence and reporting of drug errors in a district general hospital. . Source: Journal of Advanced Nursing
22(4), p628-637, 610p.
Gladstone, J. B., MSc, RGN. (1995). Drug administration errors: a study into the factors underlying the occurrence and reporting of drug errors in a district general hospital. Journal of Advanced Nursing. , 22(4), 628-637.
Kohn, L. T., Corrigan, J.M., Donaldson, M.S. (Committee on Quality of Health Care in America, Institute of Medicine) To Err is Human: Building a Safer Health System. Washington, D.C.: National Academy Press. . (1999).
Leape, L. L., Brennan, T.A., Laird, N. et al. . (1991). The nature of adverse events in hospitalized patients: Results of the Harvard Medical Practice Study II..
. New England Journal of M edicine, 324(6), 377-384.
Lesar, T. S., Briceland, L. & Stein, S. (1997). Factors related to errors in medication prescribing. JAMA, 277(4), 312-316.
Nadzam, D. M. (1991). Development of medication-use indicators by the Joint Commission on Accreditation of Health Care Organizations. American Journal of Hospital Pharmancy, 48, 1925-1930.
Phillips, D. P., Christenfeld, N. & Glynn, L.M. (1998). Increase in US medication-error deaths between 1983 and 1993. Lancet, 351, 643-644.
Rich, D. S. (1998). A process for interpreting data on adverse drug events: determining optimal target levels. Clinical Therapeutics, 20(Suppl C), 59-71.
Thomas, E. J., Studdert, D.M., Burstin, H.R. et al. (2000). Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care forthcoming Spring.