運用資訊系統提高意外事件管理成效

Improve incident management effectiveness

近幾年醫院不斷鼓勵員工執行意外事件通報，至2015年年底統計發現尚有8.5%（未簽核件數／該年度通報總件數）的意外事件件數主管未簽核，這些件數其中超過100天以上的佔55.7%，於是進行PDSA （Plan-Do-Study-Act）品質管理循環。由資訊部列出報表、設計系統自動發Email通知、提報規章委員會，載明應於規定的工作天數內完成簽核、另外件數≧3件或日數超過100天以上者，再由專人用電話聯絡，了解原因並協助完成。經一週後發現簽核未完成率由9%降為3%、其中超過100天以上的由60%降為12%，未達期望目標。故再次深入探討得知：66%尚在評估改善成效、18%職務異動跨院區無法完成、16%不孰悉簽核路徑，於是未進入系統完成簽核。針對未達期望目標的原因，把焦點定在分析、處理而不只是為簽而簽。運用資訊化管理、專人協助執行改善，再次評估發現原本3%待簽核的意外事件，一週後餘1.8%、超過100天以上0%。之後將此作業設定標準化，簽核逾7天未完成者，每週一系統發通知給醫品部，追蹤至今近2年維持每週10件以下，有效改善事件通報簽核逾時未簽核的情形。 In recent years, employees are constantly encouraged to carry out notification of accidents. However, as of the end of 2015, 8.5% of the number of unidentified accidents (not signed number/ the total number of notifications for the year) were found, of which over 100 days Accounting for 55.7% of the total, so as to conduct a PDSA (Plan-Do-Study-Act) quality management cycle. Information Department, first list the statements designed to be automatically sent by Email notification and report to the rules and regulations set forth in the working days should be completed within the required number of sign; the other three or more days more than 100 days by persons Contact by phone again to find out why and help with it. After a week, it was found that the unfinished rate of sign-off was reduced from 9% to 3%, of which over 60% was reduced to 12% over 100 days, failing to achieve the expected target. Further in-depth study revealed that: 66% are still assessing the effectiveness of the improvement, 18% of job changes across the hospital area can not be completed, 16% do not know where to sign the path. So did not enter the system to complete the sign. For less than the expected goal of the reasons, the focus on analysis, processing and not just sign. Using information management, assisted by individuals to implement improvements, reevaluation found that the original 3% pending the accident, 1.8% after one week, 0% over 100 days. After this standardization of job settings, sign off more than seven days were not completed, the system sent a weekly notification to the Medical Quality and Safety Department, Track nearly 2 years now maintain 10 or less per week, effectively improve the notification of the event out of time situation.

In recent years, employees are constantly encouraged to carry out notification of accidents. However, as of the end of 2015, 8.5% of the number of unidentified accidents (not signed number/ the total number of notifications for the year) were found, of which over 100 days Accounting for 55.7% of the total, so as to conduct a PDSA (Plan-Do-Study-Act) quality management cycle. Information Department, first list the statements designed to be automatically sent by Email notification and report to the rules and regulations set forth in the working days should be completed within the required number of sign; the other three or more days more than 100 days by persons Contact by phone again to find out why and help with it. After a week, it was found that the unfinished rate of sign-off was reduced from 9% to 3%, of which over 60% was reduced to 12% over 100 days, failing to achieve the expected target. Further in-depth study revealed that: 66% are still assessing the effectiveness of the improvement, 18% of job changes across the hospital area can not be completed, 16% do not know where to sign the path. So did not enter the system to complete the sign. For less than the expected goal of the reasons, the focus on analysis, processing and not just sign. Using information management, assisted by individuals to implement improvements, reevaluation found that the original 3% pending the accident, 1.8% after one week, 0% over 100 days. After this standardization of job settings, sign off more than seven days were not completed, the system sent a weekly notification to the Medical Quality and Safety Department, Track nearly 2 years now maintain 10 or less per week, effectively improve the notification of the event out of time situation.