提昇病房護理交班完整性

A Project to Enhance The Integrity of Ward Nursing Staff Shift Reports

護理交班是護理人員每日臨床例行且重要的醫護溝通工作。本單位曾因發生交班疏漏、不確實，而延遲病人檢查之進行；期間主管亦因處理病人抱怨花費許多時間，故引發同仁進行改善動機。經現況分析發現單位護理交班完整性僅達72％，探討導致單位交班不完整因素包括：(1)護理人員無法掌握交班重點；(2)需交班事項繁瑣；(3)交班方式不一致；(4)Ka r d ex（交班單）內容雜亂。藉由修訂三班交班作業規範及kardex使用標準規範、增設交班工具輔助（健康照護問題一覽表及醫囑清單）及設計音樂提示功能等改善策略執行後，護理交班完整性由72％提昇至94％。正確完整的交班，可節省接班者再次查詢的時間，立即掌握病況，提供病人連續性和安全的照護。

Shift change is a daily routine and an important communication tool in nursing care. We had experienced delays in the examination of patients due to inaccurate or missed communications during shift change and wasted time in handling patient complaints. These issues prompted our unit to initiate a plan to improve shift change. Case study and analysis found that current shift change procedures and practices achieved only 72% efficiency. The causes of inefficiency were: (1) nurses did not master the key points at shift change； (2) shift change items were too complicated； (3) shift change procedures were not standardized； (4) the content of the Kardex (shift change form) was confusing. Simplified and standardized procedures for shift change, the same Kardex used for all 3 shifts, as well as patient health report, doctors’ prescription reference tables and the use of a musical alarm system have improved the efficiency of shift change from the previous 72% to 94%. A proper and efficient shift change will enable t incoming shift personnel to immediately grasp the patients’ health status, reduce time for corrections, and provide continuous and safe nursing care.