執行手術劃刀前Time Out之改善專案

A Performance Improvement Project: Time Out Verification Right Before Surgical Operation

自2002年發生多起醫療院所之醫療不良事件造成多人傷亡後，直接衝擊到醫療院所與消費者的醫病關係。本專案旨在結合醫療團隊合作執行手術劃刀前Time Out，以提升醫護人員對手術病人安全之認知，進而落實維護手術病人安全。經小組分析發現醫護團隊缺乏執行Time Out作業標準；對於手術劃刀前Time Out缺乏共識。影響因素包括：主刀醫師希望麻醉好立即下刀；接刀時間太緊迫，無時間執行Time Out；病人情況緊急，無法等待；以及流動護士暫時不在，無法進行雙向核對。經專案小組制定Time Out作業標準，舉辦教育訓練，張貼提醒海報及標語，訂定獎勵辦法及製作英雄榜海報，建立稽核制度，以及未執行Time Out流動護士不遞送刀片給醫師。手術劃刀前Time Out執行率由12%提升至76%達目標。

Since year 2002, many adverse medical events in the hospitals have not only caused patient deaths, but have also impacted the relationship between health care professionals and patients. This project aimed to increase awareness of patient safety and promote safe surgical operation by means of time out verification. The analysis of the study indicated the issue of lack of standard for time out verification. The surgical team did not always perform time out verification. The surgeon started operation right after the patient was prepared by the anesthesiologist The tight surgical schedule caused time shortage for time out verification. The patient was too critical to wait until the process of time out verification was completed. The circulating nurse was not available for the implementation of time out verification. The performance improvement project included set-up of standard for time out verification, staff training, height light posters for time out verification, criteria for recognition and the recognition display poster, and initiation of an audit system; without performing time out verification, the circulating nurse will not hand the operational blade to the surgeon. The implementation rate of time out verification rose from 12% to 76%, and reached the goal.