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1{Y{U59tUflUU Original Article

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Quality Improvement to Reduce Problems Associated with Enoxaparin

Administration in One Ward of Mae Sot Hospital Tak Province, 2oo0-2oo7

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Ampun Katvilat Cerb Nursing B.Ed,

Thinarat Wangkawee B.Sc.

Amporn Yaemsuan B.Sc.

Mae Sot Hospital

Tak

Sawanpracharak Medical |ournal

VoLr No.e SeptemberDecember zooa

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avv: fl1:U:?11:u1, fl1:ilflUfqrUnrn0r1un1:yrg1U1A, enoxaparin

Abstract

Obiective

Setting

Design

Subiects

Method

Results

To study nursing problems associated with Enoxaparin administration

and to evaluate quality improvement to decrease Enoxaparin administration

problems.

Special ward(l) at Mae Sot General Hospital, Tak province

Survey

56 patients receiving Enoxaparin in 2006-2007.

Medical records of patients receiving enoxaparin in this ward were reviewed.

surveillance of nursing problems and adverse drug effects, particularly

bleeding in these patients was carried out. Planning and evaluation of

nursing quality improvement to reduce the problems following enoxaparin

administration were conducted,

53.8% of the patients in 2006 and 50.0 % in 2e0Z were 61-80 years old.

There were more males than females. The majority of the patients had

acute myocardial infarction (42.9"/o) unstable angina (90.4%\, or transient

ischemic attack (12.5'/"). Nursing problems associated with enoxaparin

administration identified in 2006 were inaccurate technique for drug

injection (53.8%), repeated site of injection (46,2%), and inaccurate time

of injection (19.2%). Other problems included are no surveillance of

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adverse drug effects, no information about previous history of related

diseases and anticoagulants, and no health education materials. These

problems were found to decrease significantly following nursing quality

improvement in drug administration. The incidence of bleeding in the

patients also decrease after the improvement program'

Conclusion I Continuous nursing quality improvement can reduce problems or risks

associated with high alert drugs and achieve patients' safety.

Key words : Drug administration, Nursing quality improvement, Enoxaparin

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fl aJul n €un1y{a fl 1.1 FIO tUa.:5r ru nlu na1 nTauq-5f-.-4 | 6lvv\ qvv a AaLu?]Lh:',tu Qrt? u Lfi ,ill? EJ [nTUU5n1:fr a UAy

o1 a i J! e vu Alfi1fiTA n?1rJ 161U.:7ltn ar{a.: nl

^^--.4^----- - d f efl1:U??1',]Tfl',] enoxaparin iluur[uruaornt

?, a to u fl 1 u 14 a { n,t r Ft1 tu u.l,'t u y't 0)J u 1 q fun 1 y,l

firu nr:u arrrn In ar1rymr 6o.,: rn nfi n n1:fi Fr

! r Y \4y t dv o eu1 t8J 0 n n a\: Lnn n a{a u1.,1 ilu u d1 Afl fl ,1.,:f,

fr 6{ o --

orniatlac ss.a tufl 2549 riounr:firuurAYvu

nfunl?\ lfi aa:ouas 1 0.0 R.tfl ?1n.:n1:]laJu1q

qrunrvl'lufl 2sso d?un1:fr ot urdroirurmilt 6rud t du o ufr n n a.: a d r.: fi ria rir r{'rX n r.,: a fi fi or n 5 ailax 46.2

rfifiaiaaac o.z rlr-ur.mflu 1 iirfiurfla.:#u

n1:ui141:sl enoxaparin fi uur&irunorn.:

rziu rd EJr niu rirmiu ar nr:flr.: u6 a.:mtanms..----y. ie u ^ , X ounTnuaundlFt6u?a.tn1:u5fi1:Ej1neiruil 6a

R1?Br6anaa nfi uua}iilnnn{ Ior uriaunr:

du 2 u ' { 6 a et q

Lruaorrrcunl.:dA m a eirrl:fr nrrufi .:rrfi,j,rflr1ur rJ a o afiU- ,

- o i-v

fi a1 uil 6ufi 1 u Ltu? [uil n n a{},t1 fl fl ,1 EJfi A{ n1T

v tdv vyir-zu ur rrri fi ci.: l l u r]rU r r rr"'.: n ri r a'[u sir ue u ri a u fl : ilI9,-tadqryJz1{6{ [?iu rnnunnr:ilortlr'Lrinnda.] fr.:dru{ { _'--'[rr!rfi nornnr:o-orrirfirhakinn fra.: nlr6nu.rqir fl r .: l n' u r riu r 5 at ri a all f, r r r a.: rr u r a y n^ a! !4 A v v e eh t dLIJ O \: r,l ? fi U{}1 U1n A.:? A\: rf il? U n A U A n El1 [Lny4Adaaud6,y3Jfl1Tfl FrfiT0nA{rJ?fi u{fi n{anu1 rilunu-o1 - -- , X qev A uu 6u141 tfi A1U n?T LA TU nlTylUTt? U rTt ail r)Ju1

n run'r ilr a Ei1.: oi a rfi a.: ri otrl

rlqlrru6onrrru rdu.ofi lfr urf,a.: niu

n1:uifi1:u1 enoxaparin dfiuurlfiruaBrn.:

ou1{tn taufl1 EJmn,: nTru?unlTyr zuu1Flfufl1?r

tfiri{u dnr?a na{fl a{ ar nr:flr.: r6 a.:m6anrryq

..---^v.- -.-d: - , loLrnTnflaundln6ufl a\:n1TUi?l1:U1nqeJil Fa

n 1 ? s L 6 o n a a Fl (5-7)

d.o r f,l u n'r : yz a.,: yt&.,t tiiuq

LSnT :uncffLfruinr rda,rfl n firh Ej fra.:'lfi nn.]{q

'[unt:uouI:.:flururnurudu rf,arir'lfisi'ru ilIzumnrufll]ryluR.nsrdaoaanairrrurj.rfifiorsrq

tlitu?tuI3oirufru"Lunr:6amrruuuilz :rruytt:frdraun" Tau g :1El R,t?srdarroanlu:ruum1{6ua1?1l:

ud a u A - A^ 3nTaun:23Jn?1il?nnn{?atfl Et? fl ila1n1:ylLRaf, il daufru 1 :1Er LmcRrecu6anoanrlrorJfl 1 :.ru{Jc, v 4- d a o , ia:1U{luutlJun']0U1{fl4{nlIv{F}lu1 fr.tana.:Lfidofl1?yuaaBroangirttfiu.,:noorflr

y vt Ar4v- Aa d u o A vnfuf,i1TlFl1un1:illu'lu1a ryU?uTlIFr:uulTtiJ tflu.: 1 flfl muma.:rn:Fntnu{luytomrnrunrnqq9

ttd s ol-ud 3 n.u.-6.a. 2s5t

Hnnr:r(orurqornrluCaaailqt.ttornnr:uit'tt:ttt enoxapuin 1ur'ro#il:a

I:lnururauilaon iluinnrn iJ n.a. zoas-zsso

Quality Irnprovement to Reduce Prcblems Associated wih Enoxaparin Administation

in one ward of Mae so. Hospiial" Tax Provincg zooa-zoo? 955

aaanflnn::iltJ:untfl

vav da,J? A EIZ O? A U n ilU1 El L!1\Tl U ?Tl El1{.1

a{ahr ofi n.: ri firufir nd ru.,:ru trtn::il #{ n ilqqr , *tlv, d o ^- AL:.lil UIUlA Uil6An?1 LFrt? il tfi AA LUfl 1:?AEJU

OAtonflt:o1{o{

1. n:iln?unilI:n n:svt:2{d181:6ud?1.ql

il zsq+-zs+g. fir.rr(nfrd t. uuvrui,q

fvra,X-cdn1un1:6]lL:n Lil fl n na na:{ LLavnlTUl n tau

fn?sJn?unil[Tn nTen:?.,]d1fi'lTilqfl ; 2550.

4.

2. n:ern?unilI:n fl:BYl:?\:d1f,''l:fud?l. :1u\:lutJanr:rir:rnnqfin::illdil{hrrhjfioroiaqq

Lrarfl1:u1Frr6u n.rt. 2548. firudn#.:d 2. n?{L7lv'l3Jfi1un:: a',:6nr:4.:ln:1yfm}11:

r.irufin; 2sso.

3. aia.:n::ru a:6uLr6t{. n1Tlru1u1afiilrul:nr-?'[attacfiaagrL6on. firuv{nfod z. ?au[riu:qq

na'.,:ururin ffii 2549.d d aa e t d - -l u u6l

16m:r Q4ilfl, rr[rXF5 dunlsR1fi, vt?{2n1 nina{. R1?s?nqntnzJ?num?LattasAdaada

fiaoor6an. "Lu: i6n:r flqiln, u::tuflfl1T. n1:1lu1u1a{r-hunT:vinqn. firur{n{',:dcv

2. n:{t11vlillfi1un:: dililTct1l{1t1llil; 2546. llul 125-70.

s. quul 6unrie"'nuni, afzuur lw1{mtuila, LuA qadsJq:ni. nr:uiu1a?11{mf{n::ilA I v Y\ - a r o dr

rfianrrruilnaorn'Bzateitl:u. tanal:il:vnaunr:il:rzruiz1n.l:il:tii1fl v.n. zsqtqq

dtJlFrilm#tnr:ilI:\11\Et1u1n (il:;tnrtlns); 19-21 y{qunlrAN 2547; f1!{tl1ltu.lfi1lJAi;

2547.

Hirsh J, Anand SS, Halperin JL, Fuster V. Guide to anticoagulant therapy: heparin,

a statement for healthcare professionals from the American Heart Association.

Circulation 2001; 103: 2994-3018.

Hirsh J, Warkentin TE, Shaughnessy SG, Anand SS, Halperin JL, Raschke R et al.

Heaparin and low molecular weight heparin : mechanisms of action, pharmacokinetics,

dosing, monitoring, efficacy, and safety. Chest 2001; 119 (Suppl 1): 61S-94S.

6.

7.

956 rirfru frniErn, iufinrl ftnril, tirru udrr:u d?:r,i'tj:e{rindrrtor:

C o .._ e yh Jty-Ft"t:1\:il 1 a1u?ultacfaHasfla.ozudrtlfrldiugt enoxaparin qir[unn,]ua1El tilflunrn''l:efioo'ErI:n

v?aila{

il.fl.2549 y{.FI.2550 t?3Joaa1u?u :oflas

oyo1u?u :oga3

cyo1u?u iaEjac

"UQ1U?Uyh:?1tJFt

arq Gt)

40-60

61-80

>90

tTI F[

91U

tt{.0aa uf

fl1:?UAAEtTn

Acute myocardial infarction

Unstable angina

Transient ischemic attack

lschemic heart diseaseJ0u9

26 100.0

30.8

53.8

15.4

63.4

34.6

38.5

23.1

15.4

1 1.5

11.5

100.0

40.0

50.0

10.0

70.0

30.0

46.7

36.7

10.0

0.0

6.7

100.0

35.7

51.8

12.5

67.9

32.1

30 56

20

.297

38

18

12

15

3

21

9

I14

4

17

o

10

o

4

3

3

14

1'1

3

0

2

24 42.9

17 30.4

7 12.5

3 5.4

5 8.9

fl nnr:rifl rtquntnrdonaiqnnrnnr:lirt:at enoxaprin luno{tJ:u'lxuuuratrilron {lrinnrn fl n'4. zols-zoso

fld s srud s n.s.-'.n.2ss1 **T#T,'"3I*XH,iT,.-

Jq/Aoan1T1{fr 2 ilrufi11]v'lu [Un1TU?fi1191 enoxaparln

r}ynrdnu.Y{.FI.2549 (N = 26) Y{.fl.2550 (N = 30)

oya1u'tu :agac a1u?uIl0ga3

P-value

rlrgvn'[unr?uiil'tru1dr|ty- rYlnunfl 1:anu1 tilQnno\:

dY"- AnEl'l{1 n1Ltfi U\:LAIJ

- :sErcL?aflun1:Anlilrt:',:

rl1ilur{un1:inw1uJuq?114u 1

- hi n:rurl:vah nr:'[fi fl r fi1udva

n1:Ufli9l??O\:tAAtlt rd A v qe

- Luiltondl:fi:o?lailan1:l?1

nmruluri{rhnrnsrpAtuu9 9V

n1:n ltA nU tO\:m A\: LFI:U U1

- hi fi m:{hil:vihl:nil:vdr d'rA A e t ovntnEJ?fl4{nau ttEll

- hifirmrflrsi.,:rm:urnnfrou 17

dt v d- Arilua1 s a nu6uo n u:Lvl o fl 1:

d.:oia

14 53,8

12 46.2

5 19.2

3

2

1

10.0

6.7

3.3

0.0

20.0

23.3

< 0.01

< 0.01

0.06

< 0.01

< 0.01

< 0.01

< 0.01

26 100.0

100.0

69.2

65.4

26 6**

0

7

0.018

. u1{:1ufi1l6ufi1sJ1nn'j1 1 aEh.l

-" r{lufrdrsoir.:grfi

o'rfru ffniars, iurisni i{nrl, drn: ufua.ru. dt u d

6t??:FtU:31',1:fl ut?u 6t1t

rlr:1{d s R1?srrm?n#audnutu{,rhudtfiiuEt1 enoxaparin

11.F,.2549 (N = 26) Y{.FI.2550 (N = 30)vR1?sttfl:nt,au P-value*oya1u?u :aflac

o9a1u?u :ouas

- fl1?claoaoan (hematoma)o'Aa

n1UfiU.:nAnfl'l

fl1?s16onaantu:vuu

n1{ rAualilr:drufru (upper

gastrointestinal bleeding)

R1?sL6AnAAflm1{Oiln

(epitaxis)

11.5

3.8 0.00

3.9 0.06

0.03.8

T?3i 19.2 3.3

:?ilr'I1?stdanoanlilTcuuml{t6ua1fi1rd?ufru LraeRl?E[6onaafln1{otJn rdaltlunr:rdAvAorJa

ru:EJU r?1 UU nURl2ctaO nfl Afl 0t1 tt?lil.,:fr fr n s,1