- 期刊
降低腦中風急性後期病人吸入性肺炎之發生率
Reduction of Incidence of Aspiration Pneumonia in Patients with Acute Stroke
摘要
腦中風病人常見吞嚥困難情形，因嗆食導致吸入性肺炎發生，更會增加腦中風的死亡率。本專案採用醫療照護失效模式與效應分析（Healthcare Failure Mode and Effect Analysis, HFMEA）進行跨部門的風險管理方案，以改善吞嚥評估流程，並降低急性後期病房吸入性肺炎發生率。回溯2017年1～6月急性後期病房住院過程中發生吸入性肺炎，篩選出16項潛在失效原因，規劃教育訓練、增設吞嚥困難篩檢紀錄表、執行標準作業流程與多元性及客製化的衛教工具、定期執行稽核等策略之推動。實施後，失效潛在原因由16項下降至0項，吸入性肺炎發生率由17.4%降至0。應用HFMEA進行品質改善計畫，確實能有效改善吞嚥評估流程，未來仍應持續進行系統性監控，以提供病人安全的就醫環境。
並列摘要
It is common for stroke patients to have difficulty swallowing, and aspiration pneumonia caused by choking can also increase the death rate of stroke. Healthcare Failure Mode and Effect Analysis (HFMEA) was adopted to identify potential swallowing risk to improve the process and reduce the incidence of aspiration pneumonia in the Post-Acute Care ward. In backtracking from January to June 2017, it was found that aspiration pneumonia occurred during the ward where 16 potential failure causes were screened out while education and some interventions were implemented. The potential cause of failure dropped from 16 to 0, and the incidence of aspiration pneumonia dropped from 17.4% to 0. The application of HFMEA for quality improvement programs can indeed effectively improve the swallowing assessment process. In the future, systematic monitoring should be continued to provide a safe medical environment.