改善血液透析機警報發生之專案

Project for Dialysis Machine Alarm Improvement

血液透析機正常運作關係著病患安全，頻繁透析機警報干擾病患身心健康。經分析問題為透析機警報平均每班高達215次，導致原因有：一、缺乏新型透析機操作手冊。二、手臂固定暨保暖、術後廔管走勢圖等設施欠缺。三、護理人員謹為度、透析操作知識與技能皆不足。四、缺乏透析機繼續教育及透析標為技術監測機制。專案目的在降低透析機警報發生率達118次以下。解決辦法有：一、製作透析機操作手冊。二、增設手臂固定暨保暖板及廔管走勢圖。三、成立獎勵制度。四、舉辦繼續教育及定期監測標準技術。改善後透析機警報發生平均每班降低至116次，結果顯示達專案目的。本專案建立透析機警報處理的原則，改善成果及創新手臂固定暨保暖板，可作為其他透析單位警報發生改善之參考。

Patient safety relies on the normal operation of the dialysis machine. Frequent alarms caused by equipment malfunction can affect patient health. Our investigations found that up to 215 alarms were triggered per shift. Causes included: no user manual for the new dialysis machine, equipment shortages such as the arm fixer/warmer and blood vessel trend chart; nurses' lack of caution, knowledge and skill on dialysis operations; a lack of continuing education on dialysis machine operation and no monitoring mechanism for standard dialysis procedures. The purpose of this project was to reduce the frequency of machine alarm to less than 118 per shift. Solutions included: Compiling a user manual for the dialysis machine; installing additional arm fixers/warmers and including the blood vessel trend chart on the patient's chart; setting up an incentive scheme; as well as provide continuing education and regular monitoring of dialysis procedures. After the improvements were made the frequency of machine alarms decreased to 116 per shift. This project has been a success and provides a reference for improvements to dialysis machine alarms in other units.