# 情境 護理師正在更換用完的PCA袋。幫浦標示為morphine 1 mg/mL。藥局新袋標示hydromorphone 0.2 mg/mL。幫浦即將重啟。優先護理為何?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375175&lang=zh-tw  
> language: zh-TW  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PA

## 題目

情境 護理師正在更換用完的PCA袋。幫浦標示為morphine 1 mg/mL。藥局新袋標示hydromorphone 0.2 mg/mL。幫浦即將重啟。優先護理為何?

## 選項

1. 兩者都是鴉片，劑量會自動調整，重啟即可。
2. 先重啟幫浦，下劑給完後再聯絡藥局。
3. 在不一致解決前停機且不重啟；與另一位執照護理師執行獨立雙人核對醫囑、藥名、濃度與幫浦程式；以新醫囑重新設定為hydromorphone 0.2 mg/mL；以條碼與醫囑比對藥袋；記錄；並再衛教任何藥物或濃度變更皆為高警訊查核點。 **✔ 正確答案**
4. 為避免浪費，將剩餘的morphine與hydromorphone袋混合。

**正確答案: 3**

## 解析

PCA程式錯誤已被廣泛紀錄，且常致命，發生於成人與小兒。最常見兩種：(1) 藥名輸入錯誤 — 袋為hydromorphone卻設為morphine或反之，可造成最多7倍劑量錯誤；(2) 濃度錯誤 — 袋為0.2或5 mg/mL卻設為1 mg/mL。ISMP最佳實務：(1) 任何藥物、濃度或藥袋變動均為高警訊查核點，必須在床邊由兩位執照護理師獨立雙人核對醫囑、藥名、濃度、劑量上限、basal/demand/lockout、病人識別與幫浦顯示；(2) 採用具藥物資料庫與dose error reduction software (DERS)的smart pump；(3) 支援時掃描藥物與病人(BCMA)；(4) 全院濃度標準化以減少混淆；(5) 幫浦上貼活性藥物與濃度標籤；(6) 不可假設鴉片等效 — 同樣demand量下hydromorphone 0.2 mg/mL與morphine 1 mg/mL總劑量不同。未經驗證重啟、混合剩液、延後聯絡藥局皆不安全。護理師應停機、核對、重新設定、重啟前再雙人核對。

## 深入解析

藥物或濃度更動為高警訊查核點。停機、核對、重設、雙人核對 — 不得以原程式自動重啟。

## 重要概念

- **PCA programming error** — 錯誤藥物/濃度程式錯誤，致命，需smart pump加DERS加BCMA加濃度標準化
- **independent double check** — 兩位執照護理師獨立核對：藥物、濃度、上限、顯示、病人ID
- **smart pump + DERS** — 藥物資料庫、dose error reduction software、機構標準化、整合BCMA

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