壓力性損傷(Pressure injury)簡稱壓損,為醫療照護品質的重要指標,本單位自2019年1月至9月發生17件壓損,其壓損發生率為0.316%,高於全院病房閾值(0.115%),故而引發本單位進行專案深入探討,經由分析原因有對於預防壓損認知不足、每日皮膚完整性評估未落實、翻身擺位未確實執行、管路固定及使用不正確、翻身輔具不足。改善措施包括定期舉辦預防壓損在職教育、提供臥床病人翻身輔助工具、制定預防壓損流程、制定多國語言翻身卡、使用BIPAP者新增減壓時間等。經專案改善後,評值期間未有壓損發生,壓損發生率為0%,顯示本專案成效。期望經專案小組分享後能降低病房壓損之發生,以提升病人照護品質。
Pressure injury is a key indicator of the quality of medical care. Between January and September 2019, 17 pressure injuries occurred in this unit. The pressure injury incidence rate was 0.316%, which was higher than the hospital-wide average (0.115%). The causes were discussed in depth and identified as insufficient awareness of pressure injury prevention, failure to implement a daily skin integrity assessment, improper implementation of repositioning, incorrect tube fixation and use, and insufficient repositioning aids. Improvement measures included regular on-the-job education on pressure injury prevention, provision of repositioning aids for bedridden patients, development of pressure injury prevention procedures, development of multi-language repositioning cards, and a new decompression time for BIPAP users. After the implementation of these measures, no pressure injury occurred during the evaluation period, demonstrating the measures' effectiveness. By sharing this experience, we expect the incidence of pressure injury to be reduced and the quality of patient care to be improved.