降低手術室護理人員尖銳物扎傷件數之改善專案

手術室通報以尖銳物扎傷案件，持續兩年位居全院之首，為改善此狀況遂成立專案小組，期望降低護理人員尖銳物扎傷件數。本專案運用通報資料分析、檢視單位規範與院方政策比對、以查檢表檢核遭扎傷通報兩次（含）的人員，進行結構性質性訪談等方法，確定主因為單位的規範和院方政策不一致、未將預防手術室護理人員尖銳物扎傷課程納入新人訓練、協助手術過程傳遞器械時均以「手傳手」方式。經決策矩陣分析表，擬定醫護人員正確傳遞器械課程、製作預防尖銳物扎傷教學影帶、工作同仁執行手術室時全面戴雙層手套等七項之具體方案。結果呈現預防尖銳物扎傷措施之正確率由43.67%提升為86%；尖銳物扎傷件數由年平均17件降至11件。達成專案改善目的，營造手術室安全文化。

關鍵字

手術室護理人員；間接傳遞法；尖銳物扎傷

並列摘要

Injury from sharp objects has been among the highest of all reported injuries in operation rooms for the past two years. Therefore, a project team was formed to reduce such injury cases. Analysis of cases has been performed. Rules of procedures have been compared with the overall goal of the hospital. Structured qualitative interviews have been arranged with people who had experienced injury. The reason has been nailed down to inconsistency between rules of procedures conducted on the ground level and that which is expected from the top, the absence of such prevention training for newcomers, and the traditional practice of hand-to-hand technique when passing sharp instruments. A decision-marking matrix was used to decide on making changes. Continuous education courses have been revised to include such safety education, while video clips have been made to show exactly how to do it, and a new measure has been adopted that two layers of gloves should be worn. The result is that for prevention measure cases, the rate went up from 43.67% to 86%, while injury cases were reduced from 17 to 11. This is a success story achieving project goals and improving safety measures in the operation rooms.

並列關鍵字

Nurses in operation room ； Hands-free Technique ； Sharp-object injury

參考文獻

黃嗣棻、蘇喜、戴玉慈(2012)‧某醫學中心醫護人員工作中尖銳物扎傷與相關因素之初步探討‧護理暨健康照護研究，8(2)，117-127。

林綉珠、黃璉華(2014)‧世紀回眸-護理執業工作環境之演變與發展‧護理雜誌，61(4)，35-45。

Ogg, M. J. (2014). Clinical Issues. AORN Journal, 99(1), 166-175.

Lakbala,P., Sobhani, G., Lakbala, M., Inaloo, K. D., & Mahmoodi, H. (2014). Sharps injuries in the operating room. Environmental Health and Preventive Medicine, 19(5), 348-353.

EPINet針扎防護通報系統(2017)‧2015年針扎分析‧取自http://meeting.ilosh.gov.tw/epinet/DF/105_re port .pdf