以ISBAR執行單位內交班之改善專案

Performance Improvement Project：Using ISBAR for Hand－off Report

本院以醫策會2008至2009年病人安全八大目標為推行病人安全政策，期望單位針對目標六提升醫療照護人員溝通的有效性，落實交接班。2008年7月1日至7月7日經本小組稽核護理人員執行單位內ISBAR交班完整率為59.3%，且調查護理人員對執行ISBAR交班滿意度為55.6%。主要原因為交班標準不夠清楚佔24.2%、交班Kardex表單不符實際需求佔21.2%、交班Kardex資料夾不符實際需求佔18.2%、不知道交班重點及順序佔15.2%、未有交班稽核制度佔12.1%、忙碌忘記佔9.1%。經執行改善方案：以ISBAR原則修訂單位內交班標準、以ISBAR原則制訂單位內交班單、明訂攜帶至病人單位交班之表單、更換交班資料夾及制訂交班稽核辦法後，ISBAR交班完整率為88%，護理人員對執行ISBAR交班滿意度為88.2%，達專案改善目的。

Based on the eight patient safety goals, issued by Taiwan Joint Commission on Hospital Accreditation in 2008, each healthcare department is expected to improve effectiveness of communication and accuracy of shift hand-off The monitoring findings on hand-off report, done from July 1 to 7, 2008, revealed that the integrity rate of TSBAR hand-off report was 59.3%, and nurses' satisfaction percentage to the implementation of ISBAR hand-off report was 55.6%. Several concerns included unclear standards for accurate hand-off (24.2%), the impractical hand -off Kardex form (21.2%) and the Kardex file holder (18.2%), disorganized report without highlights (15.2%), unavailable monitoring tool (12.1%), and incomplete report due to forgetfulness (9.1%). An improvement project was implemented, including revision of the departmental standard for hand-off report by using the TSBAR format, redesign of the hand- off report form, change of the Kardex file holder, and set-up of a monitoring tool. The integrity of hand-off report was increased to 88% and nurses' satisfaction was up to 88.2%. The goals of the project were achieved.