| Summary: | 碩士 === 高雄醫學大學 === 醫務管理學研究所碩士在職專班 === 94 === Abstract
Background
Reducing medication errors and improving patient safety have become major issues in hospital management. Medication errors occur for a variety of reasons, including inaccurate communication and deficits in knowledge and performance by and among all health care professionals. Health care professionals can play an important role in protecting patients from adverse effects of medication errors. Therefore, the aims of this study were applying failure mode and effects analysis (FMEA) to enhance the safety of medication administration by implementing computerized education system and E-processing of bed side medication administration.
Materials
Qui-experimental (before and after) design was used in this study. 27 new nurses (employeed under three months in the hospital) and 143 nurses were recruited from the case hospital. Using FMEA to identify problem areas and develop computerized process to prevent medical errors as the main intervention methods.
Results
During the 3 months study period we conducted a total of 22 new employed nurses and 143 nurse who undertook tests of correct identification of medication in a e-learning system. Expect 5 new nurses quit their job during this time. The pilot results showed that nurses’ perspective of lower medication scores were drug interaction (2.54?b0.56)、 knowledge about max. safty medication dosage (2.52?b0.64) and confidence in medical administration (6.70?b2.11). The highest scores of factors of medicine errors were feature similarity (4.0?b0.71) and reading difficulty of prescription (4.04?b0.72). Post test results showed that the knowledge about pharmacology was significantly increased after intervention program (36.0?b2.85 vs40.33?b4.09; p＝0.012). The confidence of medicine administration was significantly increased after intervention program (102.13?b15.03 vs 117.13?b14.39; p＝0.001)。The results of E-learning and E-process improvment decreased medicine errors to zero. This study showed significant improvement in medication safety through FMEA application and computerized medication education.
Conclusions
Success in achieving significant changes was associated with effective processes and appropriate choice of intervention. Successful teams were able to define, clearly state and relentlessly pursuer their aims and intervention processes. The finding of this study may help hospital administrators to apply FMEA method in preventing medication errors and other areas concerning patient safety.
Key words: failure mode and effects analysis (FMEA), medication safety, IT and medication administration
|
|---|
