降低精神科病人異物哽塞發生率

Reduce the Rate of Choking Incidents Among Psychiatric Inpatients

住院病人意外事件的預防，是病室管理的重要工作，本院在2015年發生3件嚴重異物哽塞事件，經緊急處置仍造成嚴重的傷害，引發本院組成跨團隊專案小組管控；經由調查2015年1月1日至12月31日的異物哽塞異常事件通報及現況分析發現異物哽塞相關因素為：進食評估未持續、缺乏異物哽塞高危病人評估、食材烹調不符病人需求。藉由落實病人進食評估與規劃高危用餐區以利觀察、建立異物哽塞高危險病人篩檢機制及作業標準、營養室食材改善；結果異物哽塞發生率由十萬分之1.8降低至0％，異物哽塞致死率由67％降低至0％，異物哽塞高危病人標準作業完整率達96％。本專案針對相關危險因子採取必要管理措施，有效降低異物哽塞發生率，提升照護品質。 This is very important for ward management to prevent accidents in hospitalized patients, In 2015, three serious choking incidents in Mental hospital, Although the emergency treatment immediately still causing serious injury, Causing us to form a cross-team to control. Through the investigation from January 1 to December 31, 2015, choking incidents recorded and the current situation analysis found that related factors associated with choking incidents: Eating assessment is not sustained, lack of high-risk patients assessment with choking incidents, food cooking does not meet the needs of patients. By the implementation of the patient eating assessment and planning high-risk dining area to observe, to establish of high-risk patients screening and standards operating with choking incidents, nutrition room to improve food. As a result, the rate of choking incidents from 1.8/per 100,000 to 0%, and the rate of choking deaths from 67% to 0%. The project for the relevant risk factors to take the necessary management measures to effectively reduce the choking incidents, improve care quality.

This is very important for ward management to prevent accidents in hospitalized patients, In 2015, three serious choking incidents in Mental hospital, Although the emergency treatment immediately still causing serious injury, Causing us to form a cross-team to control. Through the investigation from January 1 to December 31, 2015, choking incidents recorded and the current situation analysis found that related factors associated with choking incidents: Eating assessment is not sustained, lack of high-risk patients assessment with choking incidents, food cooking does not meet the needs of patients. By the implementation of the patient eating assessment and planning high-risk dining area to observe, to establish of high-risk patients screening and standards operating with choking incidents, nutrition room to improve food. As a result, the rate of choking incidents from 1.8/per 100,000 to 0%, and the rate of choking deaths from 67% to 0%. The project for the relevant risk factors to take the necessary management measures to effectively reduce the choking incidents, improve care quality.