Pai-Yu Huang, Yi-Jyun Shen, Min-Huei Hung, Mei-Chuan Wu,Chiao-Chin Ku, Yu-Hsuan Chen, Ping-Chih Shih

Objective: This study aimed to reduce medication errors among emergency department (ED) nursing staff through the application of Quality Control Circle (QCC) methodology and Healthcare Failure Mode and Effect Analysis (HFMEA), thereby enhancing patient medication safety and improving overall healthcare quality.

Methods: A retrospective analysis was conducted on six medication error incidents that occurred during 23,980 emergency visits in 2022, with an error rate of 0.25‰. Using system diagrams and HFMEA, six root causes and five potential failure modes were identified, including insufficient experience, lack of structured training, failure to follow complex procedures, unclear labeling, and similar appearances of medications. Based on these findings, six improvement strategies were implemented: (1) strengthening onboarding and inservice training, (2) simplifying the verification process by promoting the “one-read, fiverights” protocol, (3) establishing audit and reminder mechanisms, (4) revising the emergency drug inventory and implementing smart medication cabinets, (5) introducing barcode-based electronic patient identification, and (6) enhancing IV bag labeling and visual management. All strategies followed the PDCA cycle for execution.

Results: Following implementation, the medication error rate in the ED dropped from 0.25‰ to 0‰, significantly improving medication accuracy and patient safety, while also increasing staff compliance with protocols and confidence in medication administration.

Conclusion and Discussion: This study demonstrates that systematic analysis and collaborative teamwork can effectively improve the medication administration process in emergency settings. Ongoing efforts should focus on continuous staff training, workflow optimization, smart technology integration, and interdepartmental collaboration to sustain improvements in patient safety and healthcare quality.

黃沛榆，沈奕均，洪敏慧，吳美娟，古巧琴，陳育萱，施秉志

目的：本研究旨在透過品管圈與醫療失效模式與效應分析（HFMEA），改善急診室護理人員給藥錯誤情形，降低錯誤率，提升病人用藥安全與醫療品質。

方法：採回溯法分析2022年急診室23,980人次就醫紀錄中的6件給藥錯誤事件，錯誤率為0.25‰。研究運用系統圖與HFMEA進行根因分析，確認6項真因與5項潛在失效模式，包括年資不足、教育訓練缺乏、流程複雜未落實、標示不清及藥品外觀相似等問題。依據分析結果，規劃六項改善對策：一、強化新人及在職教育訓練；二、簡化核對流程，推動「一讀五對」；三、建立稽核與提醒機制；四、調整常備藥物與導入智能藥櫃；五、導入電子病人辨識掃碼系統；六、強化點滴標示與目視管理。所有對策均依PDCA步驟實施。

結果：改善後，急診室給藥錯誤率由 0.25‰ 降至 0‰，顯著提升用藥準確性及病人安全，同時增加護理人員的流程遵從率與工作信心。

結論與討論：本研究證實，透過系統性分析與團隊合作，能有效改善急診室給藥流程。建議持續實施教育訓練、優化作業系統、導入智慧化工具，並推動跨部門合作，以達成病人安全與醫療品質雙重提升的目標。