57 提升護理人員執行化療給藥步驟之正確性 -- 不良事件根本原因分析之應用 黃雅儀廖美琪 * 陳燕錫 ** 鄧慶華 *** 給藥錯誤一直是醫療院所普遍存在的問題, 其發生大多起因於護理人員未依標準步驟執行給藥, 本文旨在描述中部某區域教學醫院於 2008 年 1 月發生一起化療給藥錯誤之不良事件後, 護理品質小組運用 根本原因分析法, 改善不良事件 提升婦產科病房護理人員執行化學治療給藥步驟正確性之專案改善 過程 小組於 2008 年 2 月 24 日至 26 日針對全體護理人員進行化療給藥步驟之稽核, 發現所有人員均 未通過查核 經分析發現護理人員執行化療給藥步驟不正確之根本原因屬於系統層面之問題, 包括 : 醫囑開立不清晰 缺乏醫護作業標準 缺乏相關教育 資訊設計不完善 故根據文獻資料及矩陣分析 決定改善策略, 包括 : 統一醫囑形式 系統建立及標準化 舉辦教育訓練及資訊系統更新 策略實施 後化療給藥步驟之正確率可提升至 100%, 本專案之改善經驗可作為臨床第一線管理者進行不良事件分 析改善之參考 不良事件 根本原因分析 化學治療 給藥正確率 51 3.7% 19.4% Thomas et al., 1999Taxis Barber20032 10 49% 1% 2005Davis, Lay-Yee, Briant, & Scott, 2003 2008 1 Hovor & O Donnell, 2007 34 6580%2007 26 2 14 120.3 8.52.53 * ** *** 97 6 25 97 11 10 98 3 9 699 04265819194403
58 Promotion of Accuracy of Medication Administration phyxol caboplantin 810 23 50 2008224 226 100% 58.33% 100% ㈠ 1. 124~1 25 2. 3. 1. 0 0 % 2. 7 58.33% 3. 0 0 4. 0 0 5. 0 0 6. 0 0 7. 0 0 8. 12 100% 9. 0 0 10. 0 0
59 1/18 14:47 / phyxol carboplatin 1/18 15:00 phyxolcarboplatin 1/18 15:30 1/18 16:00 1/18 16:10 1/18 16:15 1/18 16:30~24:00 phyxolcarboplatin physol 1/19 0:00-0:30
60 Promotion of Accuracy of Medication Administration - ㈡ 2008 226228 12 12 100% 39% 38% Leape et al.,1995
61 Brown, 2001 2005 36.8% 28.9% 23.7% 34.2% 2005 Shojania, Duncan, Mc- Donald, & Wachter, 2002; Wu, Lipshutz, & Pronovost, 2008 2005ReedBleganGoode1998 GoldspielDechristoforoDaniels2000 Root Cause Analysis, RCA 2007 1997 RCA Boyer, 2001 2 1 14 5 4 5 14 5 5 5 15 5 4 5 14 5 4 5 14 5 5 2 12 551
62 Promotion of Accuracy of Medication Administration 1/212/3 2/42/17 2/183/2 3/33/16 3/173/30 3/314/13 4/144/27 4/285/11 1. 2. 3. 4. 5. 1. 2. 1. 2. 2008121511 ㈠ 2008 121 330 1. 2. 229 3 29 3. 58.33% 4. 229 2 2 5. 2008333 30 35 RCA 330
63 ㈡2008225~5 2 1. 228327 2. 429 430 43052 ㈢ 2008 325 ~511 325511 55 511 0% 100% 325427 10 229328 14:30 / 100% 329 4 29 DattiloConstantino2006 2002
64 Promotion of Accuracy of Medication Administration 2007 5467783 2005 71 6573 2005 1744146 Boyer, M. M. (2001). Root cause analysis in perinatal care: Health care professionals creating safer health care system. Journal of Perinatal and Neonatal Nursing, 15(1), 4054. Brown, M. M. (2001). Managing medication error by design. Critical Care Nurse Quarterly, 24(3), 7797. Davis, P., Lay-Yee, R., Briant, R., & Scott, A. (2003). Preventable in-hospital medical injury under the no fault system in New Zealand. Quaityl Safety Health Care, 12(4), 251 256. Dattilo, E., & Constantino, R. E. (2006). Root cause analysis and nursing management responsibilities in wrong-site surgery. Dimensions of Critical Care Nursing, 25(5), 221 225. Goldspiel, B. R., Dechristoforo, R., & Daniels, C. E. (2000). A continuous-improvement approach for reducing the number of chemotherapy-related medication errors. American Journal of Health-System Pharmacy, 57(4), 49. Hovor, C. & O Donnell, L. T. (2007). Probabilistic risk analysis of medication error. Quality Management in Health Care, 16(4), 349353. Leape, L. L., Bates, D. W., Cullen, D., Cooper, J., Demonaco, H. J., Gallivan, T., et al. (1995). Systems analysis of adverse drug events. The Journal of American Medical Association, 274(1), 3543. Reed, L., Blegen, M. A., & Goode, C. S. (1998). Nurse staffing and patient outcomes. Nursing Research, 47(1), 4350. Shojania, K. G., Duncan, B. W., McDonald, K. M., & Wachter, R. M. (2002). Safe but sound: Patient safety meets evidencebased medicine. The Journal of American Medical Association, 288(4), 508513. Taxis, K., & Barber, N. (2003). Ethnographic study of incidence and severity of intravenous drug errors. British Medical Journal, 326(7391), 684687. Thomas, E. J., Studdert, D. M., Newhouse, J. P., Zbar, B. I. W., Howard, K. M., Williams, E. J., et al. (1999). Cost of medical injuries in Utah and Colorado. Inquiry, 36(3), 255 264. Wu, A. W., Lipshutz, A. K. M., & Pronovost, P. J. (2008). Effectiveness and efficiency of root cause analysis in medicine. Journal of the American Medical Association, 299(6), 685687.
65 Promoting the Accuracy of Chemotherapy Medication Administration for Nurses: An Application of Root Cause Analysis Ya-Yi Huang Mei-Chi Liao * Yen-Hsi Chen ** Ching-Hua Deng *** Abstract: Drug administration error in the hospital ward is an ever-present problem and an all-too-frequent occurrence. Such errors are often made by nurses who fail to follow relevant nursing standards. The aim of this article was to describe an adverse event of chemotherapy-related medication error that happened in an academic hospital located in central Taiwan. The authors and their colleagues used root cause analysis to survey the adverse event and to suggest ways to improve the accuracy of nurse chemotherapy medication administration. We investigated medication administration of chemotherapy made by nurses between February 24th and 26th, 2008, and found that a number of nurses failed to administer medication properly. Based on data analysis, root causes were identified as: (1) directed prescriptions were unclear, (2) chemotherapy medication administration lacked protocol guidance, (3) education was insufficient and (4) computer systems were inadequately designed. Based on a literature review and matrix analysis, the task force identified four major categories in which improvements were needed. These included: (1) prescription promotion, (2) protocol development and standardization, (3) education for healthcare practitioners and (4) improvement of computer systems. After improvements were put into practices, the accuracy of chemotherapy medication administration by nurses increased to 100%. We shared the promotion experience with clinical managers to analyze and avoid adverse events. Key Words: adverse event, root cause analysis, chemotherapy, the accuracy of medication administration. RN, MSN, Supervisor, Department of Nursing, Tungs Taichung MetroHarbor Hospital; *RN, BSN, Assistant Head Nurse, Department of Nursing; **RN, BSN, Department of Nursing; ***RN, MSN, Supervisor, Department of Nursing. Received: June 25, 2008 Revised: November 10, 2008 Accepted: March 9, 2009 Address correspondence to: Ching-Hua Deng, No. 699, Zhongqi Rd. Sec.1, Wuqi Town, Taichung 43503, Taiwan, ROC. Tel: +886 (4) 2658-1919 ext. 4403; E-mail: t7033@ms.sltung.com.tw