導入團隊資源管理降低針灸科門診病人中藥薰蒸燙傷發生率之改善方案

To Reduce the Herbal Steam Scald Incidence of Acupuncture Outpatients by Team Resource Management

本專案旨在導入團隊資源管理降低針灸科門診病人中藥薰蒸燙傷之發生率，藉由調查與分析燙傷原因為病人對熱不敏感及認知不足，自行縮短薰蒸距離及延長薰蒸時間、護理人員未蓋緊薰蒸瓶蓋及未固定蒸氣出口裝置、承接煮沸藥液之薰蒸瓶無防燙功能、蒸氣出口裝置缺乏凹槽及藥材游離分子過大造成阻塞等，經導入政策領導及團隊合作，介入中藥薰蒸注意事項衛教海報、薰蒸機操作說明標示、在職教育、研發薰蒸瓶保護套、會同工務課研發承接水滴出口裝置及增設測量尺、會同中藥局改良薰蒸液及專科品管制定品質監控指標等措施，中藥薰蒸燙傷發生率由5.1%降至0.2%，改善幅度達96.1%，期望本專案導入團隊資源管理之改善經驗能作為類似案例的參考。

The project aims to apply team resource management to reduce the rate of herbal steam scalds occurred in acupuncture outpatients. Through the investigation, the causes of scalds were those patients not sensitive to heat. Besides, due to the insufficient knowledge, they shortened the distance of herbal steam and extended the treatment time against advice. Further, some nurses neither covered the steam caps tightly nor fixed the steam exporting part of the device. The steam bottle undertook boiled liquid did not have anti-heat facility, and steam exporting part of the device lacked an indentation, and probably the sticky steam particles of herbs caused blocking. By applying policy guidance and the team cooperation, we made the patients’ instruction of herbal steam treatment and paid more attention to staffs training. We also developed the steam bottle protector, and consulted the engineering team to develop a water droplet exit device with a measurement scale. Furthermore, we discussed with herbal pharmacy to improve the herbal solution and better quality control. The incidence of herbal steam scalds reduced from 5.1% to 0.2%, and the improvement was 96.1%. We hope that the mprovement experience by applying the team resource management project can be a reference for similar events.