隨著病房新進護理師人數增加，執行複雜的血腫治療給藥過程，經常發生認知不足致藥品相容性，及給藥順序錯誤異常事件，分析原因為未統一血腫治療用藥安全相關教與學內容及方式、缺乏整合性用藥安全注意事項，及繼續教育訓練、臨床教與學負荷大，且照顧經驗不足所致。此專案目的為，提升護理師於血腫治療用藥安全認知，及護理師對於血腫治療用藥安全訓練計畫的滿意度。經跨領域團隊整合常見療程，製作依疾病分類，及英文字首檢索之彩色版血腫用藥安全教育訓練紙本手冊、QR code及線上學習資源，護理師對於血腫用藥安全認知，由69.4%提升至99.8%，維持成效期可達目標；對整體訓練計畫的滿意度，由71.8%提升達94.8%且達目標值，改善後效果維持，皆未再發生血腫治療藥品給藥錯誤異常事件，有效提升用藥安全。

With the increase in nursing staff number, during the administration of complicated chemotherapy in hemato-oncology cases, incidents of drug incompatibility and administration sequence errors resulting from suboptimal cognition also increased. The reasons might include ununified educational material and strategy for hemato-oncology medication safety, a lack of integrated precautions for medication safety and continuous education program, and high teaching and learning loads with suboptimal experience. This current project aimed at improving the nursing staff’s cognitions of medication safety and correctness as well as the satisfactory rate of the training program. With the unification of standard regimens by inter-disciplinary teams, a compilation of medication safety training brochures with color labels for different disease classifications and alphabetical sequences, and making use of QR codes and online learning resources, the cognition rate for medication safety increased from 69.4% to 99.8% with the durability of effect achieving the goal. The satisfactory rate of the whole program improved from 71.8% to 94.8% and the improvement persisted without the further occurrence of medication incidents, greatly improving medication safety.