- 學位論文
虛驚事件定義對呼吸治療師意外事件分類之影響
The Effect of Near-miss Definitions on Classifying Respiratory Therapist Incidents
摘要
醫療本質即包含著不確定的因素，其來源包括儀器、設備、醫療人員的技能與團隊間的合作程度。處於高度緊急與忙碌的環境下，不管是無易的失手或瞬間的猶豫，醫療的疏失有可能造成異常事件，甚至危及到生命。本研究目的是期待呼吸治療師瞭解虛驚事件之定義，可即時清楚區分與提報，也藉由團體案例分享後，讓人員提升對於虛驚事件產生的警覺。除此之外，進一步有能力針對虛驚事件判斷其後果的可能嚴重程度，將有限的資源放在對嚴重程度高的虛驚事件之調查，以達到有效降低異常醫療事件產生。 研究方法採橫斷式設計與自擬結構式問卷，內容主要有呼吸治療師職場上之25題案例，透過參與焦點團體的醫療人員判斷何者為”虛驚事件”與”未造成傷害的異常事件”。第一次在無任何暗示下進行判斷；第二次先給予Reason瑞士乳酪模型的說明，再進行判斷。關於第二階段的自陳式虛驚事件提報，由同一批焦點團體自我提報過去一段時間之虛驚事件，接著讓參與進行分享，再提報一次。最後，由團體成員共同討論評估此25題案例的潛在後果嚴重程度。 問卷初始先依衛生福利部之”虛驚事件”名詞，針對呼吸治療師職場25題案例進行調查，第一次調查答對準確率為 69.6%；再由”Reason瑞士乳酪模型”重新定義”虛驚事件”名詞後進行第二次調查，答對準確率達 90.3%。最後藉焦點團體法，自我提報自身之”虛驚事件”發生次數，發現在團體討論分享後，工作環境或是日常生活無論是看到或發生”虛驚事件”之次數統計有明顯增加。針對呼吸治療師師職場25題案例中是屬於”虛驚事件”案例再進行辦別”可能產生嚴重傷害”的團體共識為62.5%。 研究過程中發現Reason瑞士乳酪模型的說明可使得”虛驚事件”的定義更簡易清楚。可使人員易於辨識醫療現場中發生的意外事件，並進一步分析何者屬可能產生嚴重傷害的事件，進而通報主管，改善相關的因素。藉由經驗的分享，資淺人員將可獲得更多經驗，映射於自我經驗中，當事件發生時立即自我辨識，是可以降低異常事件產生。
並列摘要
Objective : The nature of medical treatments is involved with many uncertain factors, which include physical instruments, facilities, human skills, and cooperation among team works. Any medical error, no matter which is slip or lapse arising in the intensive working atmosphere could cause abnormal events, even harm to a life. One way to reduce medical errors is the promotion of near miss reporting. One of the aims of this study is to investigate how the ways of defining near miss event and no harm event affect the accuracy of classification of these two kinds of events in near miss reporting. Another aim is to understand how much level of safety awareness can be lifted via group discussion of self-reporting medical events. The final aim is to differentiate the potential significance of near-miss event. The limited resources should be spent on investigating those events which could cause significant harm to reduce medical errors. Methods: In the first phase of this study adopts the cross-sectional approach with a structured questionnaire, which include 25 questions to be classified as either a near-miss event or a no-harm event by participants with/without the hint of the Swiss-Cheese model. In the second phase, the comparisons of the number of self-reporting medical events by medical staff are made between before and after a group discussion on the reported events. In the third phase, the set of 25 questions are discussed and scrutinized to reach consensus on their significance of potential harm. Results: In the first phase of the study, the correct classification with the hint of the Swiss Cheese model is 90.3% while it is 69.6% without the hint. In the second phase, after a group discussion on the reported events, the number of self-reporting events increases. And the consensus among the focus group is reached to determine that 62.5% of questionnaires are potential to cause significant harm. Conclusion: The application of the Swiss Cheese model help the participating medical staff correctly classify the medical events. The group discussion on the self-reporting medical events help improve the safety awareness among the participants and increase self-reporting cases.
參考文獻
延伸閱讀
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