影響病人安全相關因素探討-以中部某區域教學醫院為例

「病人安全」不僅是醫療品質的基石，也是醫療照護者和病人之間的共同目標，藉由異常事件的通報與收集，從已發生的錯誤或跡近錯失事件中進行檢討、改善或學習，避免相類似的事件重覆發生，事先做好的預防措施。本研究主要探討陪伴者是否在場與藥物事件、跌倒事件、醫療照護事件、管路事件、檢查檢驗事件發生率、相對危險性、相對危險差為何。本研究為回溯性橫斷描述性研究，研究對象為2014年至2018年中部某區域教學醫院，住院中曾發生異常事件病人，依據研究目的以卡方檢定(chi-square test)分析。統計結果顯示藥物事件陪伴者在場陪伴異常事件發生率233‰；陪伴者未在場陪伴異常事件發生率356‰；相對危險性陪伴者未在場陪伴異常事件發生率是有陪伴者的1.5倍；相對危險差陪伴者未在場陪伴異常事件發生率和有陪伴者的比較相差123‰。跌倒事件陪伴者在場陪伴異常事件發生率160‰；陪伴者未在場陪伴異常事件發生率233‰；相對危險性:陪伴者未在場陪伴異常事件發生率是有陪伴者的1.4倍；陪伴者未在場陪伴異常事件發生率和有陪伴者的比較相差73‰。醫療照護事件陪伴者在場陪伴異常事件發生率238‰；陪伴者未在場陪伴異常事件發生率124 ‰；相對危險性:陪伴者未在場陪伴異常事件發生率是有陪伴者的0.5倍；相對危險差: 有陪伴者在場陪伴異常事件發生率和陪伴者未在場的比較相差114‰。管路事件陪伴者在場陪伴異常事件發生率193 ‰；陪伴者未在場陪伴異常事件發生率150 ‰；相對危險性陪伴者未在場陪伴異常事件發生率是有陪伴者的0.7倍；相對危險差有陪伴者在場陪伴異常事件發生率和陪伴者未在場的比較相差43‰。檢查檢驗事件陪伴者在場陪伴異常事件發生率174 ‰；陪伴者未在場陪伴異常事件發生率134 ‰；相對危險性:陪伴者未在場陪伴異常事件發生率是有陪伴者的0.7倍；相對危險差: 陪伴者有陪伴者異常事件發生率和未在場陪伴的比較相差40‰。透過資料統計及分析，期望提供未來醫療院所於給藥、預防跌倒、醫療照護、管路照護及檢查檢驗異常錯誤防範上，藉以設置最完善的照護系統，進而提供病人與家屬安全的醫療環境。

關鍵字

通報系統；病人安全；異常事件

並列摘要

A patient’s safety is the foundation for medical quality and the goal between the caregiver and patients. The preventive measurements are the result of collaborated information from reporting of abnormal incidents or errors soon-to-be made/ already made. To study the measurements from mistakes and refine the processing can prevent the occurrence of repetitive mistakes. The study focused on the patient’s safety on the aspects of: medication events, fall events, medical care events, intubation events, examination and laboratory events . A companion’s background such as age, gender, and marital status; a medical professional’s condition such as day/ night shift, site of the incident, objects affected by the incident, personnel related to the incident, and Severity Assessment Code were all the factors to be taken into account for the purpose of the research. The study used cross-sectional, retrospective, descriptive studies approach to survey from the patients in an central region teaching hospital between the year 2014 to 2018, with chi-square test for the analysis. The analysis suggested medication events, The incidence rate of unusual events occurring was 233‰, when the companion was present in comparsion to Taichung；The incidence rate of unusual events occurring was 356‰, when the companion was not present；Relative Risk 1.5x；Attributable Risk 123‰。 For the fall events, The incidence rate of unusual events occurring was 160‰ when the companion was present in comparsion to Taichung；The incidence rate of unusual events occurring was 233‰, when the companion was not present；Relative Risk 1.4x；Attributable Risk 73‰。 For the medical care events, The incidence rate of unusual events occurring was 238‰, when the companion was present in comparsion to Taichung；The incidence rate of unusual events occurring was 124‰, when the companion was not present；Relative Risk 0.5x；Attributable Risk 114‰。 For the intubation events, The incidence rate of unusual events occurring was 193‰, when the companion was present in comparsion to Taichung；The incidence rate of unusual events occurring was 150‰, when the companion was not present；Relative Risk 0.7x；Attributable Risk 43‰。 For the examination and laboratory events, The incidence rate of unusual events occurring was 174‰, when the companion was present in comparsion to Taichung；The incidence rate of unusual events occurring was 134‰, when the companion was not present；Relative Risk 0.7x；Attributable Risk 40‰。 Through the statistics and analysis of relevant factors, the researcher hopes for the future to provide medical institutions with the most comprehensive care system for administration of abnormal errors in medication events, fall events, medical care events, intubation events, laboratory and examination events Therefore, set up the most comprehensive care system and provide safe medical environment for patients and their families.