以系統導向事件分析法進行中心導管照護系統安全性之探討

Applying System-Oriented Event Analysis Model to The Safety of Center Catheter Care Systems

林世華(Shih-Hua Lin)

指導教授 ： 莊秀文

臺北醫學大學/公共衛生暨營養學院/醫務管理學研究所/碩士(2015年)

https://doi.org/10.6831/TMU.2015.00064

摘要

研究動機：自1990年美國國家科學院附屬醫學研究機構 (Institute of Medicine , IOM)提出「To Err is Human: Building a Safer Health System」，建構安全的衛生系統已成為現代醫療產業所追求的目標。而中心導管相關血流感染是加護病房常見的問題，不僅耗費醫療資源，嚴重更可能有致命的危險。因此，中心導管組合式照護措施被廣為推行。然而，2010年美國國家健康照護安全網絡 (National Healthcare Safety Network, NHSN)研究卻發現實施中心導管組合式照護與其造成的血流感染並沒有顯著相關性，而醫療照護人員的遵從性普遍亦未盡理想。因此，了解中心導管組合式照護作業其間深度的互動交叉關係即成為一項很重要的課題。另外，近年來以應變工程(resilience engineering)提升系統安全新思維的發展，帶來提升病人安全新的契機。故此，本研究運用系統性分析法及應變工程的觀念，進行中心導管照護作業系統安全性的探討。
研究目的：包括三項(一)、釐清中心導管照護作業系統的現況；(二)、開發出應變工程結合系統導向事件分析模式的方式；及(三)、建置中心導管照護作業系統的安全性控制結構。
研究方法：本研究的研究場所為某區域醫院之加護病房，使用系統導向事件分析法(System-Oriented Event Analysis Model, SOEA )以及質性分析深度訪談法，針對中心導管照護作業系統以預防血流感染的作業，進行系統分析與應變工程的研究。
研究結果：針對中心導管照護作業系統為了維持病人生命及避免因置管而產生感染的目的，SOEA系統分析釐清該系統內有三個重要的次系統進行交互作用；同時在中心導管照護作業系統日常運作的過程中，有9種潛在或已存在的系統危害。然而在2015年1月1日至2015年3月31日期間，共有15例暴露在這些危害情況之中的病人，僅有3例發生中心導管相關感染，並未全部遭受的血流感染。針對這種情況，透過深度訪談醫師與護理人員，發現第一線臨床人員，處於相同引發系統危害的各種情況下，有相同或不同的反應作法，以維護其系統實作的功能而能繼續執行工作，並降低可能造成病人傷害的風險。換言之，本研究運用SOEA剖析出中心導管照護作業系統的結構，釐清此系統中各項元件之間的關係，並結合應變工程了解在此系統中，臨床人員如何在每日面對系統的危害，以及可預期與不可預期的各種發生情況之下，適應性地調整其中心導管組合式作業方式，而非一味地遵從，並能維護病人安全的做法。
結論：應用SOEA除了可以提升系統思考的能力與強化系統改善的整合性之外，亦可呈現系統的完整結構，使一個過去認為的抽象醫療照護系統的概念，呈現具象化，包括系統的關聯性、有序性、目的性，提供系統改善重要的資訊。SOEA結合應變工程的效果，展現系統應變分析的能力，可協助醫療人員了解應變方式的發生與學習管控的方法，唯有充分認知系統結構與該系統內成員的應變能力之後，才能達到建構安全醫療體系的目標。

關鍵字

系統性分析、應變工程、加護病房、中心導管相關血流感染

並列摘要

Background: At 1990 Institute of Medicine (IOM) proposed "To Err is Human: Building a Safer Health System", the construction of safe sanitation systems have become a modern medical industry objectives pursued. central line-associated bloodstream infections (CLABSI) occurring in the intensive care unit (ICU)are common, costly, and potentially lethal, Central line (CL) bundles to prevent central line-associated bloodstream infections (CLABSIs) are widely promoted. However, in 2010 the studies also a policy for the CL bundle is often present but frequently not well implemented by National Healthcare Safety Network (NHSN). Therefore, understanding the center catheter care systems during the depth of the interaction cross relationship becomes a very important issue. In addition, in recent years, to develop resilience engineering bringing new opportunities to enhance patient safety. Therefore, the study Applying System-Oriented Event Analysis Model and resilience engineering to the safety of center catheter care systems.
Objectivs: Includes three (a) To clarify the status of the central catheter care systems, (b) The application of resilience engineering in System-Oriented Event Analysis Model, (c) To building a safety control architecture of central catheter care systems.
Methods: This study used System-Oriented Event Analysis Model (SOEA) and qualitative research interviews in an Intensive Care Unit of regional hospital.
Results: The study found the goals of central catheter care systems to save patients live and control the CLABSI, in system-wide, there are three important sub-systems of working system functions to achieve system goals. Use SOEA, we found that there are 9 kinds of hazards in the central catheter care system. However, sampling a total of 15 cases of exposure to hazard among those in January 1, 2015 to March 31, 2015, only 3 cases to get the CLABSI. In view of this situation, interview doctors and nurses, found that HealthCare worker, in the same system hazers caused by the various states, have the same or different reaction practices to maintain their system and can implement functions continue to work, and may reduce the risk of patient injury. In the other hand, the SOEA can clarify the relationship between the various elements of central catheter care systems, combined with resilience engineering to understand HealthCare worker that how to respond the system in daily hazards, and under the anticipated and unanticipated occurrence of various adaptively adjust its central catheter combined practices, rather than blindly follow, and to maintain patient safety practices.
Conclusion: Applying System-Oriented Event Analysis Model in addition to the ability to improve the integration and strengthening systems to enhance the systems thinking, the structure of the system can complete presentation, including relevance of the system, orderly, purposeful, providing system improve important information. SOEA analysis of the resilience of the system, allowing the HealthCare worker to understand the occurrence and learning control method reaction only after full cognitive system structure in order to achieve the goal to Building a Safer Health System.

並列關鍵字

Systematic analysis, resilience engineering, intensive care unit, Central Line Associated Bloodstream Infections

參考文獻

石崇良、廖慧娟（2009）。政府推動病人安全之成果與展望。醫療品質雜誌，3(2)，9-12。

徐宗福(2007)。根本原因在醫療照護的應用。護理雜誌，54(6)，77-83。

張雪梅、王麗華（2005）。中心靜脈導管相關的血流感染。院內感染控制雜誌，15(4)，236-241。

盛望徽、張育菁、張瑛瑛、洪美娟、洪儀珍、簡淑芬、陳宜君（2012）。落實組合式感染管制照護(Bundle care)以降低中心導管相關血流感染。醫療品質雜誌，6(3)，59-64。

陳欽明等（2010）。以醫療品質改善突破手法(BTS)來改善加護病房病人中心導管相關血流感染。醫療品質雜誌，4(3)，77-84。