前言:運用航空界的組員資源管理訓練可提升單位病人安全文化、增加病人安全與降低錯誤發生。材料與方法:以跨團隊模式組成改善團隊於成人加護病房進行改善,包括訂定需執行事前說明項目;每日三班交接班時間執行人員關懷活動;建立結構化ISBAR交班表模式。結果:參與訓練後學員們病人安全態度有很正向改變,23題人因態度問卷中有21題達統計上顯著意義,而在病人安全文化量表的部份,六個構面皆有提升;對策實施後,執行事前說明及事後檢討比率由12.5%提升至81.3%;人員關懷活動每日執行率達100%;ISBAR交班執行率由59.42%提升至93.46%;異常事件通報率由0.14%提升至0.32%;感染密度則由千分之13.3降低至千分之10.2;非計劃性氣管內管滑脫率由0.209%降至0.063%,各項指標皆有顯著改變。結論:未來將持續進行追蹤分析及檢討,建議醫療院所應及早導入團隊訓練,幫助醫療照護團隊對於病人照護發揮更大的效益與成效,降低犯錯機會及促進病人安全。
Background: The implementation of aviation crew resource management technique can reduce medical error by improving safety climate and care quality.Materials and Methods: We organized a quality improvement team in an adult intensive care unit. The interventions, including: briefing, employee care, and structural handover programs (ISBAR- I, situation, background, assessment, recommendation) were implemented.Results: The safety climate in the unit significantly improved. The unplanned extubation rates drop from 0.209% to 0.063%; and the incident reporting rates increased from 0.14% to 0.32%, but the event severity reduced significantly. The completion of ISBAR handover rates improved from 59.42% to 93.46%.Conclusion: We will continue to monitor and analyze the outcomes. We suggest early implementation of team technique to improve safety climate and care quality.