提升內科加護病房護理人員對監視器警訊聲響及時處理率

背景：美國緊急醫療研究機構（Emergency Care Research Institute）調查十大醫療技術危害項目其中一項就是「未處理的警訊，可能會有致命的後果」，且從2008年至2014年一直是名列第一。若臨床護理人員未能即時處理警訊或警覺性不足甚至是疲乏，則會對病人安全產生很大的威脅。本單位在2014年8月至2015年8月因臨床生理監視系統紅色警訊護理人員未即時積極處理，造成病人發生異常事件共有2件。目的：以病人安全考量，紅色警訊10秒內處理率由20.8%提升至100%。解決方案：擬立警訊設定標準流程、制定生理監視器警訊處理的標準流程、建立守門員制度、規劃在職教育。結果：2016年11月至2017年11月，紅色警訊10秒內及時處理率提升至100%。結論：藉由標準流程，讓人員對警訊處理有所依循且能落實完整，並運用守門員制度提升單位合作精神，讓人員體會警訊處理需共同合作。此外將生理監視器警訊及時處理率列為單位年度品管監測項目之一，持續追蹤及檢討改善。

關鍵字

生理監測系統；警訊疲乏；病人安全

並列摘要

Background & Problems: According to the Emergency Care Research Institute, ＂not responding to alarms＂ is a top-ten health-technology hazard that ranked first between 2008 and 2014. The failure of clinical nurses to respond to alarms in time due to lack of awareness, fatigue, or other cause represents a great threat to patient safety. Between August 2014 and August 2015, two patients in this unit died because the red alert on the physiological alarm surveillance system was not answered and dealt with promptly. Purpose: To raise the 10-second response rate to red alerts from 22% to 100% in order to enhance inpatient safety. Resolution: Establish standard operating procedures for alarms and for the handling of physiologic monitor devices when alarms sound; form a gatekeeper system; and arrange on-the-job training. Results: The 10-second response rate to red alerts increased from 22% to 100% between November 2016 and November 2017. Conclusions: By following standard operating procedures, personnel now have a guide to respond to and handle red alerts comprehensively. Implementing the gatekeeper system also increased the team spirit of the unit and helped personnel appreciate the importance of cooperation in handling alarms. In addition, the functions of the physiologic monitor devices and the 10-second response rate for red alerts will be included in the annual quality control checklist of the unit for follow up, review, and further improvement.

並列關鍵字

physiological surveillance system ； alarm fatigue ； patient safety

參考文獻

周靜儀、陳姿燕、羅　琦（2017）．致命性心律不整導致猝死後裝置體內去顫器病人之調適歷程．護理雜誌，64（1），120–126。[Chou, C. Y., Chen, T. Y., & Lo, C. (2017). The adaptation to an implantable cardioverter defibrillator in a survivor of sudden death due to fatal arrhythmia. The Journal of Nursing, 64(1), 120–126.] https://doi.org/10.6224/JN.000016

Graham, K. C., & Cvach, M. (2010). Monitor alarm fatigue: Standardizing use of physiological monitors and decreasing nuisance alarms. American Journal of Critical Care, 19(1), 28–34. https://doi.org/10.4037/ajcc2010651

Perrin, K., Ernst, N., Nelson, T., Sawyer, M., Pfoh, E., & Cvach, M. (2017). Effect of a nurse-managed telemetry discontinuation protocol on monitoring duration, alarm frequency, and adverse patient events. Journal of Nursing Care Quality, 32(2), 126–133. https://doi.org/10.1097/NCQ.0000000000000230

Sendelbach, S., Wahl, S., Anthony, A., & Shotts, P. (2015). Stop the noise: A quality improvement project to decrease electrocardiographic nuisance alarms. Critical Care Nurse, 35(4), 15–22. https://doi.org/10.4037/ccn2015858

衛生福利部台灣病人安全資訊網（2015）．105–106年度醫院病人安全工作目標及執行策略．取自http://www.patientsafety.mohw.gov.tw/Content/zMessagess/contents.aspx?&SiteID=1&MmmID=621273300317401756&MSID=655635445640513543 [Taiwan Patient Safety Net, Ministry of Health and Welfare, Taiwan, ROC. (2015). Patient safety goals and implementation strategies, 2016-2017. Retrieved from http://www.patientsafety.mohw.gov.tw/Content/zMessagess/contents.aspx?&SiteID=1&MmmID=621273300317401756&MSID=655635445640513543]

Google Scholar

國際替代計量

提升內科加護病房護理人員對監視器警訊聲響及時處理率

全文下載

主題瀏覽