提升加護病房病人轉送安全性之改善專案

Improvement of the Safety of the Patient Transporting Process in an Intensive Care Unit

本專案於2007年1月1日至3月31日期間，選取北部某教學醫院內科及一般重症加護病房進行病人送檢查、轉床、轉院等流程觀察、訪談及紀錄查閱等，結果發現病人轉送完整性92.1％，依醫院政策規章病人安全品質監控閾值為零異常及完整性100％。病人安全的主要關鍵在於如何改善整體照護體系的輸送及個別醫療機構內的作業流程、儀器設備及人員急救處置機制。依據醫策會2006至2007年病人安全年度目標策略「落實單位間運送病人安全之標準作業程序」進行專案改善，方案包括「舉辦在職教育訓練」、「建立重症病人轉送作業流程查核表」、「建立急救包標準及查核表」、「建立品管監測項目及案例分析機制」及「請購攜型心電圖監視器」，總稱【加護病房病人轉送安全性之改善專案】，以改善病人轉送的結構面、過程面及結果面，結果顯示：病人轉送安全性由92.1％提升至100％，經改善後人員對重症病人轉送的安全性達100％及零異常或抱怨事件發生，人員檢視及查核轉送流程，期盼透過專案的成效，激勵護理人員進行更多的工作改善，進而提升照顧品質，使病人得到更好的照顧，以達病人安全之目標。

This project was carried out during January 1 to March 31, 2007 at an internal medical intensive care unit (ICU) and a common ICU of a teaching hospital in northern Taiwan. Information regarding patient transporting process, bed exchange, and hospital transfer were collected by observation, interview, and review of the medical records. The completeness of patient transportation was 92.1%. According to the hospital regulation, the threshold value for patient transportation safely control is 100% with zero exception. The key to safety relies on a comprehensive transportation system, which includes the standard operational procedures of each individual unit, the instruments, and mechanism dealing with emergency. To achieve the goal set by Taiwan Joint Commission on Hospital Accreditation, a special project, called “Improvement of the safety of the patient transporting process in an intensive care unit” was set up. The detail of the project included implementing in-service education, creating the check table of critically-ill patient transportation, setting up a standardized procedure and check table of the portable first aid kits, establishing the quality control monitoring system mechanism, and acquiring portable EKG monitors. The results showed that the completeness of patient transportation increased from 92.1% to 100%.