Abstract
This study visualized the process from order to practice of intravenous injection by nursing staff in ICU (Intensive Care Unit) using flow diagram and analyzed the relationship between the flow diagram and the associated 31 incidents around intravenous injection reported in one year from ICU of a hospital. The visualized result by flow diagram showed that there were some communication channels from an order to its acceptance between staffs. It was clearly seen on the flow diagram that they need many information about a type, mixing and setting of drug from the preparation to practice of an intravenous injection. The analysis of the related incidents of intravenous injection compared with the flow diagram showed that there were the most incidents on selecting line and that the double check was not effective in these processes. These results showed that the flow diagram which clearly showed the occurrence of incidents by matching the flow diagram and the incident was effective to take appropriate measures.
