運用根本原因分析法改善手術室器械遺失率

Application of Root Cause Analysis to Improve the Lost Rate of Instruments in the Operating Room

器械遺失不僅造成工作不便，增加醫院成本支出，更會危害病人安全影響服務品質。本專案運用根本原因分析法進行器械遺失不良事件調查。經由現況分析發現：ㄧ、手術室人員未依作業規範之步驟執行器械點交及查檢。二、手術室未定期更新專科包盤的器械明細單。三、手術室缺乏器械查閱資料及定期安排手術器械之相關教育訓練。經文獻查證及矩陣分析選定5項改善策略，包括舉辦教育訓練、製訂手術器械資訊圖像、修定器械點交作業流程、制定自主查核作業、檢核器械包盤數量適當性並修訂器械明細單等。經方案實施其結果為：一、人員器械點交步驟正確率由67.38％提升至97.14％。二、器械遺失率由0.23％降至0.04％均達專案目的，不但減少手術時間的延誤，更提升病人的照護品質。Loss of operating room instruments induces inconvenience of work, increases cost of the hospital, endangers patient's safety, as well as influences service quality. In this proposal, we investigated events of loss of instruments in the operating room by root causes analysis. Through analyzing the real condition, we found three reasons attributable to this situation.1. The operation staff does not hand over instruments item by item according to the standard regulations.2. The detail list of instruments is not updated regularly.3. The operating room is lack of associated educational training about prevention of loss of instruments and the data of all instruments to be reviewed. Five strategies were recommended after literature review and matrix analysis, which are holding instrument-associated educational training regularly, setting up image data about instruments for operation, revision of the process in handing over instruments, development of autonomous self-review, as well as checking the suitability of the number of instrument sets and revision of detail list of instruments. After conducting strategies aforementioned, we found that the correct rate of handing over instruments increased from 67.38% to 97.14% and the lost rate of instruments decreased from 0.23% to 0.04%, which reached the goal of this proposal. Thus, we concluded that this proposal is able to reduce the delay of operation and to upgrade the care quality of patients.