提升病理科危險值通知確認率－－以某區域醫院為例

Improving the Confirm Response Rate of Pathology Sentinel Events Informing System

本研究目的為簡介個案醫院病人安全危險值通知系統，觀察危險值通知確認率之變化並初探其原因，進一步研擬提升危險值通知確認率之建議。個案醫院於96年4月建構「病人安全危險值通知系統（以下簡稱危險值通知系統）」，建置此系統之主要目的為當病人檢驗／檢查結果出現重要異常結果時，能在時限內通報相關醫護人員，以確保病人獲得即時之治療。本研究結果指出97年整體正常確認率為42%大幅高於96年的15%，正常確認率明顯提升了27%；在整體逾時確認情形方面，97年逾時確認率比96年逾時確認率降低了11%，在未確認情形方面也有明顯改善，96年未確認率高達59%，97年未確認率降為42%。根據研究結果提出三點建議，一、簡化危險值通知系統之維護作業，以提升系統之穩定性，避免系統因更動頻次而增加錯誤的機率。二、定期舉辦評值會議，同時挑選出確認率最高之科部作為標竿學習對象。三、建立危險值確認率的獎勵機制：例如：可作為科部品質指標競賽的一個自選指標。

The project aimed to understand to improve confirm response rate of pathology sentinel events. The critical and abnormal laboratory value revealed important information, and should be reported in time. A sentinel event informing system has been designed to inform physicians sentinel events as soon as possible. When the physicians received the report message by mobile phone, they should send e-mail or message to confirm they got it, in order to prevent sentinel event cases from patient death or permanent injury due to delays in treatment and make greatest efficiency on patient safety. The data of pathology was from the sentinel events informing system during 2006 to 2007 were collected. The confirm response rate in time (within 24 hours.) was 44% in 2008, which was higher than the 27% in 2007.After 24 hours (the delay confirm response rate), it was 3% lower in 2008 than that in 2007. There was an obvious improvement in the no confirm response rate in 2008 (42%) when compared with that in 2007 (56%).We used Chi-square test to analysis the data advanced and visited the related person in order to find the factor of low Confirm Response Rate. Four suggestions were provided according to the results: 1. To simplify the maintenance work of informing system in order to keep the system stable. 2. The post event review, actions, and follow-up should be initiated regularly. 3. Establish the informing system reward mechanism by setting the confirm response rate as quality indicators.4.To do little revise on the standard of informing system.