降低肝膽腸胃內科住院病人非計畫性管路滑脫發生率

Reducing the unplanned incidence rate of pipeline slippage in inpatients

林玉茹(Yu-Ju Lin) ； 歐陽慶(Ching Ou-Yang) ； 葉怡妏(Yi-Wen Yeh) ； 陳秋曲(Chiu-Chu Chen)

《高雄護理雜誌》 37卷3期 (2020/12) Pp. 45-57

https://doi.org/10.6692/KJN.202012_37(3).0005

摘要

提升管路安全為病人安全年度目標之一，單位發現2015年非計畫性管路滑脫件數偏高，不僅造成病人生命受威脅、且重新放置管路可能造成傷害、增加痛苦，甚至延長住院天數，故成立專案小組。本專案旨在降低肝膽腸胃內科住院病人非計劃性管路滑脫發生率，設定0.21%為目標值。經分析歸納出滑脫率高的主要原因有：（一）缺乏CVC、Pigtail管路衛教單張；（二）、未落實管路安全照護作業標準；（三）約束技術不正確；（四）照顧者認知不足。經確立問題，擬定對策包括：（一）製作照顧者管路安全照護衛教影片與護理人員約束技術教學影片；（二）製作管路安全照護創意衛教海報；（三）制訂「管路安全查核表」；（四）宣導管路安全照護作業標準與流程圖；（五）製作CVC和Pigtail引流管衛教單張；（六）舉辦管路安全及約束在職教育。經專案改善後，非計劃性管路滑脫發生率由0.43%下降至0.17%，顯示專案措施成效良好。期望藉由此專案提供醫護人員管路照護之改善經驗，提供個別化管路衛教指導與照護，更加謹慎減少病人傷害，提升照護安全。

關鍵字

非計畫性管路滑脫 ； 病人安全

並列摘要

Promoting pipeline safety is one of the annual goals of patient safety. We found the number of unplanned pipeline slippages was higher in 2015, leading to the patient's life to be threatened, and the need for re-insertion of the pipeline that might cause injury, increase pain, and even delay the length of hospital stay, so a specialist team was established. The purpose was to reduce the incidence rate of unplanned pipeline slippage to the target of 0.21%. The problems were established as the incidence rate of unplanned pipeline slippage: (1) lack of CVC and Pigtail catheter education leaflets, (2) unimplemented pipeline safety care standards, and (3) nursing staffs' restraint skill being incorrect, and (4) caregivers lacking cognition. Therefore, this project was implemented via six programs: (1) make pipeline safety care videos of caregivers; (2) make nursing staff restraining skill videos; (3) make pipeline safety care creative education posters; (4) formulate pipeline safety checklists; (5) set standards and flow charts for the pipeline safety standards; and (6) make CVC and pigtail catheter education sheets. After project improvement, the unplanned incidence of pipeline slippage decreased from 0.43% to 0.17%, indicating that the project measure was effective. This proposal was established through problem-solving, providing individualized pipeline guidance and care, and instructing medical staff to be more cautious to reduce injury and improve the quality of patient safety.

並列關鍵字

the unplanned incidence rate of pipeline slippage ； patient safety

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