某醫學中心急診部異常事件通報

Incident Reports in a Medical Center Emergency Department

中部某醫學中心急診部異常事件分析，提供急診醫護人員預防急診異常之參考。採病歷回溯性法，收集2007-2010 年間急診病人異常事件共110 件。急診異常事件男性佔58.2%，年齡平均54.3±19.2 歲，國小佔28.2%，檢傷級數二級41.8%，內科病人82.7%，發生班別以白班43.6%，發生地點觀察室52.7%，事件發生時無人在場佔53.6%，無傷害與輕度傷害佔48.2%、34.5%，SAC 4 級佔84.5%，護理師職級N2佔42.7%。跌倒事件50.0%、藥物事件21.8%、管路事件13.6%。異常事件發生主要因素為：病人生理及行為53.6%，人員個人因素佔37.3%、工作狀態流程設計佔23.6%、環境因素佔13.6%、使用藥物佔10%。提供急診醫護團隊病人安全相關教育訓練參考，落實常見異常相關防範措施，重度傷害事件進行根本原因分析，並加強通報營造安全文化。

This study was aimed to analyze medical events and injuries occurring while patients staying in a medical center in central Taiwan. This study can provide future references for health care workers in preventing medical incidents in the emergency room. A retrospective review of 110 unusual events in emergency patients was collected between 2007 and 2010. The majority of emergency medical incidents occurred in male patients, which accounted for 58.2% of all patients. These patients had a mean age of 54.3 ± 19.2 years, and among whom, 28.2% had an highest educational level of elementary school. These patients were also predominantly of triaged level 2 (41.8 %). Emergency medical incidents were predominant among patients in department of internal medicine, accounting for 82.7% (n=91) and medical incidents commonly occurred during daytime shifts (43.6%). There were 52.7% of the medical incidents were encountered in the observation room, however, 53.6 % of the medical incidents occurred with no observing witnesses. After the medical incident, the majority of patients had no (48.2%) to mild injuries (34.5%). The (SAC) score of most medical incidents(84.5%) were 4. Most (42.7%) on-duty primary nurse practitioners of the patients with medical incidents were of advanced N2 level. The majority of medical incidents were fall events (50.0%), followed by adverse drug reactions (21.8%), and intubation events (13.6%). The causes of medical incidents were as followings: The most common causes were associated with patients' physiological and behavior problems (53.6%), followed by personal factors (37.3%), work process design related problems (23.6%), environmental factors (13.6%), and medication usage (10%). Proper education and trainings should be given to the emergency medical staff in properly assessing patients' physical and psychological conditions in order to increase patient safety. The implementation of medical incidents prevention measures, medical incident reports, and severe medical incidents investigations can further ensure the safety of the patients and staff.