醫院病人安全文化初探—醫事人員對病人安全氣候知覺與其促進病人安全行為表現之關聯性探討

An Exploratory Study of Patient Safety Culture in Hospitals: Patient Safety Climate and its Association with Hospital Workers’ Safety Practice

施貞伶(Chen-LingShih)

指導教授 ： 鍾國彪

共同指導教授 ： 陳端容(Duan Rung Chen)

國立臺灣大學/公共衛生學院/醫療機構管理研究所/碩士(2005年)

https://doi.org/10.6342/NTU.2005.01232

摘要

背景與目標：2000年美國國家科學研究院的附屬醫學研究機構(Institute of Medicine，IOM)，出版一本有關醫療疏失報告“To Err is Human”中指出美國每年有44,000 ~ 98,000名個案因醫療錯誤死亡，估計國家醫療成本上的損失可達美金170到290億，此一聳動的結果舉世譁然。許多已開發國家的政府與民間機構紛紛投入提升病人安全活動，而建立一個病人安全文化的醫療體系往往被視為首要之選。
安全文化的量測在國外的運用行之有年，由於國內尚沒有應用於醫院的相關研究，故本研究採用由隸屬美國加州帕羅奧多市退伍軍人健康照護體系的病人安全調查中心(Veterans Affairs Palo Alto Health Care System)，以及史丹福大學的衛生政策中心與基礎醫學暨結果研究中心所共同建構「醫療照護機構病人安全氣候」量表(Patient Safety Climate in Healthcare Organization, PSCHO)，進行中文化後，用以量測國內醫院的病人安全氣候狀態，並探討其與醫事人員病人安全行為表現之關聯性。
方法：本研究為橫斷性研究，針對六家醫院所屬高階主管與醫事人員，共寄發出3,010份問卷，回收1,098份有效問卷，回收率為36.48%。
結果：以驗證性因素分析驗證PSCHO量表與自擬病人安全行為量表之因素結構。PSCHO量表在「管理與組織」、「工作效能」、「責備與羞愧感」三因素架構下，整體效度χ2(626)=3142.92 (p<0.00)，RMSEA=0.067，CFI=0.92，各題項信度指標R2值多介於0.11~0.50間，模式配適在可接受範圍；病人安全行為量表在「參與性」與「遵從性」二因素架構下，整體效度χ2(8)=14.64 (p>0.05)，RMSEA=0.03，CFI=0.99，各題項信度指標R2值除Q55為0.07偏低外，其餘皆介於0.40~0.57間，顯示模式配適良好。
經獨立性t檢定與單因子變異數分析，發現醫事人員部分個人特質與工作特質的不同，如年資、宗教信仰與否、或是是否擔任管理職等，對於病人安全氣候知覺及病人安全行為表現上皆有顯著差異。而醫事人員於不同的醫院服務或不同的臨床單位，對病人安全氣候知覺不同，顯示不同的醫院或工作單位有不同的病人安全文化，即便同樣是在醫療品質上受肯定、得過國家品質獎的醫院。
以複迴歸分析探討醫事人員的病人安全氣候知覺對其病人安全行為表現的影響，發現病人安全氣候「管理與組織」構面為「參與性」病人安全行為的重要影響因子；病人安全氣候「管理與組織」構面、「工作效能」構面則為「遵從性」病人安全行為的重要影響因子。
結論：增進醫事人員在「參與性」與「遵從性」行為的表現，最重要的影響因子為醫事人員對於組織與管理上對病人安全的支持度的知覺。

關鍵字

病人安全氣候 ； 醫療照護機構病人安全氣候量表 ； 病人安全行為 ； 驗證性因素分析 ； 病人安全文化

並列摘要

Objectives: In 2000, a medical error report published by Institute of Medicine (IOM)— “To Err is Human”, implied that at least 44,000 and perhaps as many as 98,000 Americans were dead in hospitals each year as a result of medical errors. The estimated total national costs amounted to be between 17 and 29 billion dollars in preventable adverse events. Regarding to this terrifying report, government organizations and NGOs in most advanced countries are taking actions to improve patient safety, and primary of them is to build a patient safety culture in healthcare systems.
Measuring safety culture practices for years in foreign countries. As lacking applications of such instruments in relevant domestic hospital researches, this research goes with PATIENT SAFETY CLIMATE IN HEALTHCARE ORGANIZATIONS (PSCHO), which is constructed by Patient Safety Center of Inquiry at Veterans Affairs Palo Alto Health Care System and the Centers for Health Policy and Primary Care and Outcome Research at Stanford. PSCHO is adapted with permission and translated into Chinese to measure patient safety culture in hospitals in Taiwan. Association between patient safety climate and behaviors of healthcare workers is also examined.
Methods: This study is a cross-sectional study. By mailing 3,010 questionnaires to the senior executives and healthcare workers of 6 hospitals, 1,098 samples responded (36.48 percent response rate).
Result: Confirmatory Factor Analysis (CFA) is carried out to test the factor structure of PSCHO and self-administrated patient safety behavior scale. PSCHO, with the 3 main dimensions as “management and organization,” “individual performance,” and “blame and shame,” performed a validity asχ2(8)=14.64 (p>0.05), RMSEA=0.03, and CFI=0.99. Each item performs reliability indicator (R2) between 0.11 to 0.50. Results indicate an acceptable model fit. The validity of the three-factor structure that constructed by Singer et al. was supported by Taiwan sample of healthcare workers.
Through the analyses of T-test and ANOVA, the results show that healthcare workers with seniority, religious belief, or manager position, have higher patient safety climate perception and self-report better patient safety behaviors. There are significant variations among participating hospitals, despite some of them granted the National Quality Award.
With multiple regression analysis result, we find the positive correlation between healthcare workers’ patient safety behaviors and perception of patient safety climate.

Conclusion: To enhance the health care workers’ participation and compliance in patient safety behaviors, the most important factor is to strengthen the supportive perception of patient safety in management and organization.

並列關鍵字

Confirmatory Factor Analysis(CFA) ； patient safety behavior ； Patient Safety Climate in Healthcare Organizations(PSCHO) instrument ； patient safety climate ； patient safety culture

參考文獻

7. 財團法人醫院評鑑暨醫療品質策進會，病人安全工作坊講義。2003。 Available from: http://www.tjcha.org.tw/safe/safe.asp

3. 林蘭雀，安全氣候對安全績效影響之探討—以高雄港貨櫃碼頭經營業為例。國立成功大學交通管理研究所。未發表碩士論文。2003。

12. 謝美鳳，探討安全氣候影響安全績效之研究—以國道客運駕駛員為例。國立成功大學交通管理研究所。未發表碩士論文。2003。

2. 吳聰智，台灣中部四類製造業安全氣候與安全績效之相關研究。國立彰化師範大學工業教育研究所。未發表博士論文。2000。

8. 財團法人醫院評鑑暨醫療品質策進會編印，醫院病人安全工作目標執行建議參考手冊。 2004。Available from:http://www.tjcha.org.tw/news/930531-1.htm