降低血液透析病人脫水目標誤差之發生率

Reducing the Incidence of Ultrafiltration Target Error in Hemodialysis Patients

脫水是透析治療中極重要的目的，而脫水過量造成低血壓與脫水不足致體內積水的現象一直存在，導致病人安全受到威脅。分析脫水目標誤差原因有：1.執行體重測量流程不完整 2.護理人員脫水目標設定依據缺乏一致性 3.體重計顯示值數字太多且列印功能不良 4.體重計使用空間狹窄。解決方案有：製作體重測量操作流程圖、制定脫水量依據指引、擬訂體重測量流程監測辦法、體重計列印功能的維護、調整體重計顯示數值及變更輪椅體重計置放空間。透過本專案的實施，脫水目標誤差的發生率由千分之四降至千分之二，雖未達目標，但於專案實施期間並無病人因脫水誤差而提前透析或休克的發生，讓病人及護理人員更慎重看待脫水誤差的現象，用心的預防，提供有效安全的透析治療。

Ultrafiltration (UF) is one of the most important goals in dialysis treatment. Hypotension associated with excess fluid removal or fluid overload from inadequate UF is an ever present risk for hemodialysis patients however. Errors in setting the UF target may be due to: 1. Incomplete weight measurement process. 2. Inconsistency in how nursing staff set the UF target. 3. Printing or display problems with the scales. 4. Limited space for weight measurements. Our solutions included: establish protocol for weight measurement, issue guidelines for setting UF target, monitoring during weighing session, regular maintenance on printing and display functions of the scales, and modify the space used for performing weight measurements. Since the start of this project, UF target error rate was decreased from 4% to 2%. Even though the target was not achieved, no patients experienced shock during dialysis sessions or required unscheduled dialysis due to fluid overload during the study period. The project made the nursing staff and patients more alert regarding UF errors so they can be actively prevented to provide safer and effective hemodialysis.