The Effects of the Organizational Medication Safety Policies on Nurses' Medication Errors

• Main Authors: Chia-jung Chen, 陳佳蓉
• Other Authors: none
• Format: Others
• Language: zh-TW
• Online Access: http://ndltd.ncl.edu.tw/handle/08133077399523008201

碩士 === 慈濟大學 === 護理研究所 === 97 === 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.