運用失效模式與效應分析提昇重症病人轉送安全

Improving the Safety of Inter-and Intrahospital Transport of Critically Ill Patients

本文旨在將失效模式與效應分析方式，運用於醫療照護產業提昇重症病患院內轉送安全，藉由轉送記錄進行回溯性調查，運用失效模式與效應分析，探討重症病患轉送護理人員在評估、溝通、執行與評值系統之潛在性問題，小組成員討論並決定風險優先指數，提出適當的預防措施及因應對策有：運轉教育訓練及模擬試題，加強病人於轉送前評估與途中變化之因應措施、儀器轉送前複查、抽痰機準備、後送單位確認與攜帶型呼吸器轉送前呼吸治療師備機設定、氧氣筒使用換算表、轉送前整體評估回報、動線管制評估、到達時間的安全防護與控制；並進行以上轉送評估單執行率評核，16項指標評值結果14項達閾值達且達成率為100%。藉由重症轉送安全評估單之臨床路徑方式，讓人員有安全防護機制，控制、排除潛在性作業風險，制定臨床監控評核指標，進行分析與檢討，未來除定期評核外，針對特殊情境案例進行臨床討論，並作為轉送模擬教育訓練演習之參考，建議院方對於重症病人尤其是不穩定病人之轉送，考慮培訓接受轉送訓練之固定人員，凝聚成員間對病患轉送安全共識，持續改善維護病患安全，進而避免重大風險發生。

The aim of this project was to improve the safety of inter-and intrahospital transport of critically ill patients by examining the records of transport assessment and implementing a Failure Mode and Effect Analysis (FMEA). The authors explored the nurses' assessment, communication, management, and evaluation for potential failure modes from the records of transport assessment and decided a risk priority number to provide adequate precaution and applicable strategies. The strategies are as follows: educational programs and test questions for enhancing nurses' abilities of assessment for patient before transport and coping with all kinds of problems during the process of transport, double-checking instruments and equipment before transport, confirmation of a suction machine to transport to destination and preparation of a ventilator which was configured by a respiratory therapist, a form for calculating the residual time of oxygen, overall assessment for patients and a report for the doctor, assessment for route control of transport, confirmation for departure to transport destination, and time control of arrival.Through the integration of the clinical pathways with records of assessment for transport, nurses were able to establish a mechanism of safety protection, control and eliminate potential risks, unite the member's common consensus of safe transport, and continue to improve patient safety, in the hope that serious risks can be avoided.