以ECRS技巧重建手術室骨銀行安全作業流程

Re-establish the bone bank standard operation process management for ECRS

目的：骨銀行是儲存顱骨重要的地方，因此骨銀行之管理實為重要；其存取作業之正確性，攸關著病人安全及其醫療品質，護理人員因骨銀行操作不當造成關機，以致二起家屬無法順利領取顱骨；另有一起再植入顱骨病人造成顱骨感染。本研究目的降低手術室骨銀行異常事件，以維護病人手術安全。方法：本研究於2014年4月起，經現況分析後本研究改善對策，包括醫護人員加強教育訓練及流程改造、重新建構骨銀行擺設標準並專責管理、訂定骨銀行儀器保養及維修相關規範。結果：本研究改善後骨銀行異常事件由3件降至0件，達成零錯誤目標；其附加效果：找尋顱骨時間由18分鐘降至0.3分鐘。顱骨包裝體積縮小一倍，整體空間增加1.4倍；認知測驗由68.6分上升至98.3分、滿意度由78%上升至96%。結論：本研究對提升人員執行骨銀行流程完整率具正面意義，期望尊重生命守護靈性的概念，建置Bar-code條碼化流程、顱骨包裝程序處理，並提供其他醫療機構顱骨庫安全作業管理之參考。

Objectives: Bone bank is the major place to store the skull, so that proper bone bank management is important. Accuraty procedures while storing and retrieving these bones is key factor. Involved in patients safety and the quality of health care. The main purpose of our study is adopting ECRS skills to detect the hidden problem to improve patient safety. Methods: After current analysis in April, 2014, we modified several strategies, including to further strengthen education of health care workers, adjust bone bank setting standard, equipment maintenance and repair related specifications. Results: After implementation of the project, rate unusual event rate is zore.The speed to find out proper skull by ECRS skill has devreased from 1080 seconds to 18 seconds. The package volume is 50% percent less than before. The overall space of bone bank has increased by 1.4 times. The scores of cognitive questionnaire has increared from 68.6% to 98.3%. The total degree of satisfaction has increased from 78% to 96%. Conclusions: The concept of the project has positive significance to enhance the personnel to complete Bone bank standard procedures. It is hoped that our study can provide some useful informations and suggestions to other hospitals about skull bar-code methodology in management bone bank. We also emphasize at respecting for life and spirituality concept.