化學藥物治療屬高風險性用藥，執行化學藥物治療時，如何兼顧護理人員與病人安全是癌症 護理專業之重要議題。本專案旨在提昇病房執行化學藥物治療給藥安全作業之正確率，以觀察法 及問卷調查法發現護理人員執行化學治療給藥過程正確率僅77.3%，確認主因為護理人員對化學 治療給藥步驟認知不足、設備標示不明、化學治療給藥標準規範不齊及缺乏稽核機制。專案小組 經跨團隊合作，召集藥師及醫護同仁，共同擬定化療安全給藥在職教育訓練、增設化療藥盒標示、 修訂化療安全給藥標準作業規範及建立稽核制度等方案，經專案改善後護理人員化學藥物治療給 藥安全作業正確率由77.3% 提昇至97.7%；護理人員對化學治療作業認知平均得分由71.4 分提昇 至93.8 分。運用跨團隊合作建立完善教育制度及制定標準作業流程，可促進化療給藥之安全性並 提升癌症病人照護品質。

Chemotherapy involves use of high-risk medications. The safety of patients and care providers during medication is the top priority. The purpose of this project was to promote the accuracy in administering chemotherapy. Observation and questionnaire survey were used to collect information about nurses administering chemotherapy. The results showed that the accuracy rate was 77.3%. The following problems were identified: insufficient knowledge about chemotherapy, unclear instructions on the equipment, lack of standard protocols, and lack of quality control. Strategies for this project included providing continuous education program, making standard boxes for chemotherapy, revising standard care protocol for chemotherapy, and establishing an audit system for quality control. After the strategies were implemented, the accuracy rate increased from 77.3% to 97.7%, and related knowledge score also improved from 71.4 to 93.8. By implementing the complete education system and establishing the standard protocol, the accuracy and quality of care for chemotherapy administration among nursing staff can be significantly improved.