導入團隊資源管理推展電子病歷

Use of Team Resource Management Technique to Promote Electronic Medical Record

廖玲嬋(Ling-Chan Liao)

《醫院雙月刊》 51卷3期 (2018/06) Pp. 21-26

摘要

運用航空界的組員資源管理訓練可以提升單位病人安全文化、增加病人安全與降低錯誤發生。我們因此導入團隊資源管理來推展電子病歷，其實電子病歷已被規劃為國家醫療發展的重點，近年來衛生福利部亦大力介入規劃輔導，大多數醫院均已積極發展中，不論在資訊系統建置及電子病歷管理面均已具更多的經驗，進而朝“無紙化＂發展。我們將「事前說明、事中檢視及事後檢討」的技巧應用於「跨單位團隊合作」，將「自我介紹、病況、病史、評估及建議；ISBAR」的技巧應用於「交接班」及「病況的說明」。實施一年後，發現在病人安全文化量表的部份，六個構面皆有提升，包括「團隊合作」(69.4 v.s. 78.7)、「單位安全的風氣」(70.7 v.s. 74.6)、「對工作的滿意」(70.2 v.s. 77.2)、「對管理的感受」(70.7 v.s. 73.6)、「工作狀況」(70.7 v.s. 75.5)、「壓力的認知」(72.7 v.s. 77.5)，皆有顯著的增加 (p＜0.05)。藉由此文介紹本院電子病歷實務推動現況，希望以我們經驗提供給將建置或已建置電子病歷的醫院當做發展參考。而我們未來也將持續進行追蹤分析及檢討，讓病人照護發揮更大的效益與成效。

關鍵字

電子病歷 ； 無紙化 ； 團隊資源管理

並列摘要

The implementation of aviation crew resource management technique can reduce medical error by improving safety climate and care quality. So, we use of Team Resource Management Technique to Promote Electronic Medical Record. Electronic medical record has been designated as the priority of the development of Taiwan's national health care. As a result of an extensive involvement, planning and supervision of the Department of Health, most hospitals in the country have actively engaged in developing electronic medical record, acquiring significant experience in establishing information systems and managing electronic medical records, henceforth, moving away from paper record system to paperless. The skills of TRM including ＂brief, huddle, and debrief＂ and ＂ISBAR (Introduction, situation, background, assessment, and recommendation)＂ were started in the ＂Cross-unit teamwork＂ and ＂information transfer＂, respectively. After one year of using TRM, the safety climate in the unit significantly improved (p＜0.05) in the dimensions of ＂teamwork climate＂ (69.4 v.s. 78.7), ＂safety climate＂ (70.7 v.s. 74.6), ＂job satisfaction＂ (70.2 v.s. 77.2), ＂perception of management＂ (70.7 v.s. 73.6), ＂working condition＂ (70.7 v.s. 75.5), ＂Pressure of cognition＂ (72.7 v.s. 77.5). This article describes the process, development, and its current condition in promoting the electronic medical record at our hospital. By sharing the experience of our planning and implementation of electronic medical record, we hope to help those who are interested in building a similar framework or those who may already have one. We will also continue to monitor and analyze the outcomes. In order to improve safety climate and care quality.

並列關鍵字

Electronic Medical Record ； Paperless ； Team Resource Management