運用HFMEA預防精神科病人異物哽塞之專案

本文為運用醫療照護失效模式與效益分析預防精神科病人異物哽塞之專案，2016至2018年本單位發生四件異物哽塞事件，皆對病人造成中度以上傷害，為維護病人住院安全，因而引發本專案的動機，目的為預防精神科病人異物哽塞發生，解決辦法包含增加異物哽塞相關在職教育研討、設立用餐密觀區、製作異物哽塞相關衛教影片、製作異物哽塞相關衛教文宣、制定異物哽塞風險評估表、觀察病人藥物副作用並與醫師討論調整藥物及增設食物剪刀等，結果顯示專案後至2021年10月31日止異物哽塞事件皆為0件，此專案能有效預防精神科病人異物哽塞，本專案不但為預防性、跨團隊合作之成果，亦可平行推展至其他院區精神科病房。

關鍵字

醫療照護失效模式與效益分析；異物哽塞；精神疾病

並列摘要

In this project, a healthcare failure mode and effects analysis (HFMEA) was conducted to prevent choking on patients with psychiatric disorders. Between 2016 and 2018, our unit reported four choking incidents, all of which caused at least moderate injuries. Our project aimed to ensure patient safety in our hospital and prevent choking on patients with psychiatric disorders. The interventions comprised increasing choking-related on-the-job education, setting up dining observation areas, producing choking-related health education videos, developing choking-related health education literature, formulating a choking risk assessment, observing patients' drug side effects, holding discussions with physicians about drug adjustments, and introducing the use of food scissors. After the implementation of the aforementioned interventions, no choking incidents were reported during the study time ending October 31, 2021. This project was effective in preventing choking in patients with psychiatric disorders; this form of preventive, interdisciplinary collaboration can be implemented in other psychiatric wards.

並列關鍵字

healthcare failure mode and effects analysis (HFMEA) ； choking ； psychiatric disorders

參考文獻

余文雯、黃宣宜、王愛玲、賴吟香、陳惠君(2015)．運用醫療失效模式與效應分析降低精神科住院病人異物哽塞發生率．精神衛生護理雜誌，10(2)，26－34。https://doi.org/10.6847/TJPMHN.201512_10(2).0003

Chen, C. F., Chen, Y. F., Chan, C. H., Lan, T. H., & Loh, E. W. (2015). Common factors associated with choking in psychiatric patients. Journal of Nursing Research, 23(2), 94-100. https://doi.org/10.1097/jnr.0000000000000060

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Brinn, M., & Lucas, C. M. (2005). Healthcare failure mode and effect analysis (HFMEA) approach to the control of healthcare-associated Clostridium difficile in system wide acute and long-term care facilities. American Journal of Infection Control, 33(5), e79. https://doi.org/10.1016/j.ajic.2005.04.093

Cicala, G., Barbieri, M. A., Spina, E., & de Leon, J. (2019). A comprehensive review of swallowing difficulties and dysphagia associated with antipsychotics in adults. Expert Review of Clinical Pharmacology, 12(3), 219-234. https://doi.org/10.1080/17512433.2019.1577134

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