提昇護理人員對臨床監視系統警訊處理速度之專案

Improvements in Alarm Care Speed for the Clinical Monitor System

本專案旨在提昇護理人員對臨床監視系統警訊處理速度。因淤臨床業務發現監視系統警訊聲響起，護理人員因未即時發現致病人缺氧而發生急救事件，故而觀察本單位護理人員，共計326次臨床監視系統發出警訊時護理人員的處理速度，結果發現能於10秒內立即處理者有128次（39%），10秒以上處理者有198次（61%），將198次超過10秒以上才前往處理警訊原因分析後，發現問題為：護理人員對警訊處理缺乏警覺性、護理人員對警訊設定認知不足、缺乏聯防機制、沒有聽到警訊聲、硬體設備受限、無法分辨警訊方向，因而於晨會加強宣導人員對警訊的認知、設立聯防機制、修訂監視系統設定標準及小組長查房標準、制定音量設定標準、限制訪客時間與人數，來提昇護理人員對臨床監視系統反應速度，由原10秒內的39%提昇至80%，以確保病患照護的適當性，並相對的提昇醫療品質與病患安全。

Hypoxia often occurs in the course of emergency treatment the monitoring systems alarm is not heard promptly by the nurses in attendance. In this study, nurses were monitored for the speed of their reactions to such alarms in 326 clinical instances. In 128 instances (39 percent) the nurses reacted immediately (within ten seconds), and in 198 instances (61 percent) the nurses took more than ten seconds to react. In relation to the reactions that took longer than ten seconds, it was discovered that there was: a lack of alertness about dealing with alarms, insufficient knowledge about setting alarms, no coordinated response mechanism, a failure to hear the alarm, limitations affecting the equipment and difficulty detecting the direction of origin of the alarm sound. For these reasons the hospital implemented briefings about alarms during morning meetings, a coordinated response mechanism, improvements in standards concerning the setting and inspection of alarms, the setting of limits on the frequency of patient's visits and the numbers of visitors, and the setting of a standard alarm volume level. As a result, the percentage of nurses responding within to alarms within ten seconds increased to eighty percent, raising standards of nursing care, medical treatment and patient safety.