運用根本原因分析降低手術病人壓傷發生率

本單位自2015年第一季（1月至3月）期間共發生30件因手術造成壓傷事件，手術病人壓傷發生率為0.40%，超過本院護理品質監測指標閾值0.25%。分析其根本原因為手術護理師預防壓傷相關認知不足、手術室壓傷風險評估機制不足、手術臥位擺放標準不一、減壓輔具數量不足及破損未更換等。壓傷不僅造成醫療品質及病人家屬生活品質的負面影響，亦耗費醫療資源及人力，故本單位成立專案小組進行改善。專案歷程為2015年5月5日至12月31日，主要執行措施包括實施在職教育訓練、表單及標準作業流程之制定與修正、輔具清點及保養等。具體成效為手術護理師壓傷認知得分正確率由平均59.7%提升至88.3%、手術護理師壓傷預防措施執行完整率由平均63.7%提升至92.0%、手術病人壓傷發生率由0.40%降至0.14%，達成本專案目標。

關鍵字

手術；壓傷；手術臥位

並列摘要

During the first quarter of 2015 (January to March), a total of 30 pressure ulcers instances occurred during surgeries in our unit. These pressure ulcers incidences rate in surgical patients was 0.40%, which exceeded the threshold of 0.25% in our hospital's nursing Quality Monitoring Index. The root causes are the deficiency of operating room nurses' knowledge associated with preventing pressure ulcers; the lack of pressure ulcer risk assessment mechanism and the differences in surgical position standards; the insufficiency and impairment of decompression aids. Apart from the cause of the negative impact on the quality of medical care and patients' lives, pressure ulcers also consume excessive medical and human resources. Consequently, we have initiated this project for the purpose of improving the situation from June 5 to December 31, 2015. Major implementations included on-the-job education and training; formulation and revision of forms and standards; inventory and maintenance of aids. The particular results include the accuracy of OR nurses' knowledge for preventing pressure ulcers elevated from average of 59.7% to 88.3%; the integrality rate of pressure ulcer preventive execution average increased from 63.7% to 92.0%; the incidence of pressure ulcers rate in operative patients decreased from 0.40% to 0.14%. Consequently this project goal was achieved.

並列關鍵字

surgery ； pressure ulcer ； surgical position

參考文獻

林麗華、莊馥蓮、劉秋玉、吳幸芬、唐苡甄（2016）‧某醫學中心手術臥位與手術壓傷嚴重度之分析‧榮總護理，33（1），13-20。doi:10.6142/VGHN.33.1.13

吳祚光、鍾文珍、程麗玲、戴宏達（2009）‧脊椎手術壓瘡預防與減壓擺位裝置之探討‧榮總護理，26（2），121-126.。doi:10.6142/VGHN.26.2.121

戴宏達、李榮芬、傅玲、鐘文珍、明金蓮（2002）‧影響手術病患壓瘡相關因素之探討‧榮總護理，19（1），9-20。doi:10.6142/VGHN.19.1.9

黃玉玲、林慧玲、王方、吳淑芳（2015）‧預防手術後壓傷照護流程之發展‧護理雜誌，62（6），98-104。doi:10.6224/JN.62.6.98

Choi, K. R., Ragnoni, J. A., Bickmann, J. D., Saarinen, H. A., & Gosselin, A. K. (2016). Health Behavior Theory for Pressure Ulcer Prevention: Root-Cause Analysis Project in Critical Care Nursing. J Nurs Care Qual, 31(1), 68-74. doi:10.1097/NCQ.0000000000000137

國際替代計量

運用根本原因分析降低手術病人壓傷發生率

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