本專案旨在探討骨科護理師執行負壓引流管照護不正確之相關因素,藉以保障病人安全。專案小組發現本病房2019年3月至7月負壓引流管平均每月滑脫件數高達6.8件、滑脫率為2.8%;查核護理師負壓引流管照護正確率僅71.6%,進行無法執行負壓引流正確照護之特性要因分析,發現原因為:負壓引流管缺乏一致性固定方式、缺乏照護標準規範、缺乏在職教育及稽核制度,以及未提供主要照顧者管路固定輔助工具與衛教指導單張。經針對現況統一負壓引流管固定方式及輔具、建立護理技術標準規範、舉辦訓練課程並定期稽核、修訂衛教單張等方案介入後,負壓引流管正確率由71.6%提升至97.4%;負壓引流管滑脫率由2.8%降至0.3%,專案實施過程可確保骨科護理師完整正確執行負壓引流管照護。
The purpose of this project is to explore the factors related to the incorrect implementation of negative pressure drainage tube care performed by orthopedic nurses, so as to ensure patient safety. The task force found that from March to July 2019 in this ward, the average number of slippages of the negative pressure drainage tube per month was as high as 6.8, and the slippage rate was 2.8%; the accuracy rate of the nursing staff's negative pressure drainage tube care was only 71.6%, which was impossible to carry out. The analysis of the main reasons for the characteristics of the correct care of negative pressure drainage revealed that the reasons are the lack of consistent fixation of the negative pressure drainage tube, the lack of care standards and norms, the lack of on-the-job education and auditing systems, and the failure to provide the main caregiver's pipeline fixation aids and sanitation as well as teaching guide leaflet. After unifying the fixing methods and assistive devices of the negative pressure drainage tube according to the current situation, establishing the nursing technical standards, holding training courses and regularly auditing, and revising the health education leaflet and other programs, the accuracy rate of the negative pressure drainage tube increased from 71.6% to 97.4%; The slippage rate of the negative pressure drainage tube has been reduced from 2.8% to 0.3%. The project implementation process can ensure that the orthopedic nurses complete and correctly perform the negative pressure drainage tube care.