「病人安全」為備受關注的全球醫療議題。台灣建立台灣病人安全通報系統，希望藉此系統蒐集醫療異常事件，檢討已發生事件以達成減少醫療錯誤之目的。眾多醫療異常事件中，用藥安全為重要方向之一，不當使用藥物可能危害病人的生命安全，嚴重者甚至牽涉醫療照護團隊及社會結構、增加醫療支出及財政負擔，因此透過藥物異常事件的蒐集來加強用藥安全是相當重要的。本研究主要目的為探討護理人員針對藥物異常事件的認知及其表述方式，調查影響其表述方式之因素及其對於異常事件通報的看法。
本研究依據真實事件建立開放式紙本案例通報，搭配主觀排序問卷及半結構式個別訪談。透過分析護理人員於藥物異常事件的通報模式並統計容易遺漏之通報項目來建構通報完整性與有效性分數。接著使用半結構式個別訪談探討影響護理人員使用通報模式之背後因素、實際通報標準及其對於異常事件通報之看法，最後利用排序問卷調查其通報項目主觀的重要性排序。
本研究在正式實驗的部分總共招聘了30名護理人員作為受試者，並將受試者依照其年資分為三組：「資淺組」9人，「中等年資組」11人，「資深組」10人。研究結果顯示，護理人員的通報模式分成四種：完整式通報(含完整事件闡述、檢討與建議)、部分式通報(含部分事件闡述、檢討與建議)、檢討式通報(僅提供檢討與建議)、事件式通報(僅完整事件闡述)。「年資中等組」使用最多的完整式通報及部分式通報，其次為「資淺組」。「資深組」傾向使用檢討式通報。推論其原因與通報系統設計、教育訓練方式及通報時距間隔等因素有關。三組通報結果的完整性分數與有效性分在統計上無顯著差異，但「年資中等組」有較高的分數表現，推論原因與受試者使用的通報模式、案例複雜度、參與研究的時間相關。在通報過程中產生部分項目遺漏未答的狀況，其原因為過於依賴點選式通報系統、通報習慣不佳、通報經驗不足與精神狀況不佳。在事件原因分析上，所有受試者皆能檢討個人因素，但不到50%的受試者能檢討多人因素，僅有28%的受試者能針對系統組織層面進行檢討。其原因與護理人員間普遍不存在系統導向的原因分析概念有關。在主觀項目重要性排序的部分，受試者認為與事件發生有關資訊、檢討所需資訊及病患急救所需資訊最為重要。
根據研究結果，藥物異常事件通報應加強通報系統建置及通報文化兩個部分，通報系統建置應結合人因工程設計，使通報者透過通報過程便可了解通報項目的意義及目的，避免削弱通報者本身組織事件的能力並著重於通報者認為重要的項目。通報文化應著重於整個醫療機構內對於病人安全文化的風氣改變，影響機構內醫護人員對於病人安全的態度與行為。同時也應加強護理人員觀念建立，避免資深護理人員的通報技巧生疏。透過提高最前線護理人員的通報素質，將有助於醫療安全品質的提升。

Patient safety has become a global issue. In Taiwan, the aim of Taiwan Patient safety Reporting system building is to collect and rethink happened medical adverse event from which we could learn to decrease rate of medical error. In such many kinds of adverse event, medication safety is one of main concern. Unappreciated used of drug treatment not only will threat patient lives but crush medical system and social structure and heavy the financial loading of hospital and government. It’s important to enhance drug safety through medication adverse event (MAE) collected from reporting system. The main purposes of this research are to investigate nurses’ cognition of MAE and the way they report MAE, also find out the reasons and factors behind their report and the way they look at event.
Researcher constructed open-end scenario report, subjective ranking scale and semi-structure individual interview. The open-end scenario report is based on real medication adverse events. Through the analysis of nurses reporting models of MAE and the missed items in their reports, researcher calculated the integrity and effectiveness score. The semi-structure individual interview will used to investigate the reasons behind reporting models, reporting criterion and other MAE concepts of nurses. At last, the subjective ranking scale is designed for importance ranking of reporting needed items in reporting system.
Researcher recruited 30 nurses to be participants in formal experiment. All participants were divided into 3 groups based on their working years: 9 participants for senior group, 11 participants for middle working experience group, 10 participants for junior group. In the result part, nurses reporting models could be divided into four types: “integrated report” (report with full case description, wrong doing and correction and improvement), “partial report” (report with part case description, wrong doing and correction and improvement), “review report” (report with wrong doing and correction and improvement), and “event report” (report with full case description). The middle working experience group use “integrated report” the most, and then is junior group. The senior group is prone to use “review report”. The reasons may have relevance with “reporting system design”, “training” and “report time interval”. The integrity and effectiveness score among three groups aren’t statistical significantly different, but the middle working experience group performed higher score trend than others. The reporting models, the complexity of scenarios and the experiment time may lead to this kind of results. The reasons of missing items are “dependence of click system”, “poor reporting habit” and “reporting experience” and “fatigue mental condition”. In the cause analysis part, all participants could focus on personal factors, but less than half of participants could focus on multi-personal factors, and only 28% could focus on systematic factors. Researcher infers that nurses’ concept of cause analysis which is generally not systematic oriented will causes the percentage distribution. In the subjective ranking scale part, participants think that information related to MAE, correction and patient first aid are the most important.
Based on the results, Medical adverse event reporting should focus on reporting system design and reporting culture. Reporting system design should apply ergonomics design, reporter should understand the meaning of reported items while they’re using the system. Reporting system should also avoid making user depend too much and weakening own ability of organizing report and emphasize the items reporter thinks are important. Report culture should focus on the change of patient safety culture inside medical institution. The change patient safety culture will affect staffs attitude and behavior. Training should focus on the construction of nurses’ concepts, and make them realize the importance, meaning and purpose of each reported item. Elevate front-line nurse reporting quality will do a lot on medical safety improvement.

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