The emergency rescue procedures in the hospital are complicated and require a professional team. The relative risks including patient mortality rate and medical dispute rate raise while the rescue procedure is incomplete. There were 6 medication errors and 8 near misses occurred during the rescue process from January 2019 to September 2019 due to unfamiliarity with the rescue medicines in the tray of the emergency medicine cart when nursing staff received oral orders. At the same time, it also caused the feeling guilty, anxiety and depression of the nursing staff. The aim of this project is to enhance the nursing staff understanding and awareness of rescue medicines and to strengthen the safety mechanism of drug administration.