- 期刊
手術室器械錯誤之改善方案
Improving the Instrumental Errors in Operation Room
摘要
手術室器械錯誤不僅使手術無法順利進行，延長麻醉時間，造成手術房間使用週轉率下降，工作同仁亦因此而延遲下班，影響團隊工作的氛圍，故引發本專案小組改善的動機。經本組人員現況分析與實地觀察，發現造成器械錯誤之原因有護理人員、器械室人員及手術室制度等因素，並以決策矩陣分析擬訂解決策略：(1)執行器械點交標準流程；(2)舉辦手術室器械之相關在職教育；(3)制定各科器械圖片手冊；(4)施行手術室器械多媒體教學；(5)重新分配器械室人員工作內容及專人查核；(6)使用各科器械包盤明細表；(7)安排組員跨組訓練。方案實施後，器械錯誤率由改善前0.85%，下降至方案實施後的0.35%，具體改善成效為58.8%，顯現專案改善之有效性，不僅縮短手術時間，降低病人的麻醉風險，進而提升手術房間的週轉率，達到手術室成本的控制。
並列摘要
The instrumental errors in operation room cause numerous problems including creating interruptions during operation, prolonging anesthesia time, reducing the operating room availability, prolonging working hours, making operating room a difficult environment for the staff and so on. In this study, we try to discover and to adjust these mistakes through our practical observations and analyses. We found that instrumental errors are induced by nursing staff, instrumental staff and the system rules. In order to settle these problems, we generated the following projects: 1) Setting standard procedures of hand in instruments in operation room, 2) Holding classes and work shops for instruments regularly, 3) Issuing the brochures for instruments of various operation room parameters 4) Offering multimedia education regarding the instruments, 5) Rearranging the duties of the instrumental staff with a supervisor, 6) Marking of the package of instruments in detail of different surgical specialties, 7) Exchanging the member trainings in different subspecialty teams. After these projects have been carried out, the instrumental error demonstrates 0.85% improvement and lower down to 0.35% of the post-project rate. The substantial improvement is 58.8%. This data confirms these projects are effective and beneficial. These projects not only shorten the operation time and operation hours, and lower the time of anesthesia, but also increases operating room availability and subsequently controls the expense of the operation room.