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提升血液透析護理人員血壓計操作正確率之專案

A Project for Improving the Nursing Operation of the Sphygmometer of Nursing Care Staff

摘要


完整而正確的執行血壓計操作對於病人安全是極為重要的,維護病人安全更是臨床護理師的重要職責。專案小組查核血壓計操作正確率為63.6%,經現況分析確立原因為護理師:壓脈帶未消氣、血壓計插頭未接上電源續電、不熟悉血壓計操作、未做生理監測器線路連接及固定;制度:無在職教育、未宣導及未公佈操作規範手冊;設備:缺乏提醒標示卡及操作步驟照片和中文標示。針對以上原因提出解決對策有:宣導、舉辦在職教育、公告操作步驟圖片檔及不正確操作之名單、執行監測機制、提醒標語卡的使用和操作討論會、製作功能鍵中文標示等。實施後血壓計操作正確率由63.6%提升至98.8%,專案結果顯示成效,可做為其他單位的參考。

並列摘要


Operating the sphygmometer (blood pressure meter) accurately is critical for the safety of patients. Ensuring patients' safety is essential for the clinical nursing staff. Our specialized project team reviewed the accuracy for the operation of blood pressure meters at 63.6%. The reasons for low accuracy were (1) cuff deflation was not performed, (2) power was not connected to the blood pressure meter when unused, (3) The staff was unfamiliar with the operation procedures, and (4) the monitor was not connected or fixed in place. Systematic errors include: (1) no vocational education, (2) no information announcement and (3) no instruction handbook. In regard to the equipment, we lack signs for reminder, photos for steps & guidelines, and there were no explanations in Chinese. Solutions proposed for the issues mentioned above include: announcing information on blood pressure meters, providing vocational education, notifying operation steps with pictures, providing a list of improper operators, executing monitoring mechanisms, using reminder cards, holding operation discussions, and providing Chinese translations for the buttons etc. After the adjustments were made, the accuracy improved from 63.6% to 98.8%. Results of the project were proven effective and can be used as a reference for other units.

參考文獻


尹裕君(2008).護理人力.病人安全與護理品質,榮總護理,25(4),350-355。doi: 10.6142/VGHN.25.4.350
陳玉枝(2004).從護理照護層面談病人安全.台灣醫學,8(4),528-534。doi: 10.6320/FJM.2004.8(4).10
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林玟君、何蘊芳(2011).血壓計.健康世界,55-57。
陳金德、王門傑、楊秋宏、吳玉洺 (1997).醫療儀器的使用安全概念.護理新象,7(2),574-584。

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