プロセス指向のチーム活動による誤薬防止の実践

後藤 興治; 鈴木 敬雄; 水沼 周市; 鈴木 信子; 眞野 浩; 寺崎 さよ美; 関口 智子; 後藤 達也; 武田 和憲; 齋藤 泰紀

doi:10.11397/jsqsh.13.20

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Process Oriented Team Practice for Prevention of Medication Administration Errors

Koji GOTO, Takao SUZUKI, Shuuichi MIZUNUMA, Nobuko SUZUKI, Yutaka MANO, Sayomi TERASAKI, Tomoko SEKIGUCHI, Tatsuya GOTO, Kazunori TAKEDA, Yasuki SAITO

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Keywords: Medication administration errorMedication administration error, Process management, Standardization

JOURNAL FREE ACCESS

2018 Volume 13 Issue 1 Pages 20-

DOI https://doi.org/10.11397/jsqsh.13.20

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Abstract

Authors launched multidisciplinary team, and analyzed medication administration errors according to process flow for reduction of these errors. Medication process was classified into thirteen categories. Dosing errors by patient-self were the largest in number, followed by administration errors to patients from the medication cart and order violations for change or discontinuation of medication by doctors. Main cause of dosing error by patient-self was in assessment for dosing by oneself. Thus, the assessment method was improved, and has been standardized. To reduce the administration errors from a medication cart, reconfirmation by the nurse was conducted. To improve the order violations by doctors, we ensured the awareness of the instruction manual for change or discontinuation of medication. By means of these implementation, tendency of the decrease in medication errors was observed. Process oriented team practice for prevention of medication administration errors by operating the PDCA cycle for standardization was effective.

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