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1{Y{U59tUflUU Original Article
,{ a n I :uYe}t u tq Gu n I il rfi o a o rlcy fi I o I n n I t u3m I : u r enoxaparin lu m o r$il a u
Irsilsrurauriooo ffsfiTonrn fl T{.fl. z:"As-zbbo
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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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