住院會診針灸遺漏針探討

The Investigation of Retained Needle after Acupuncture Treatment of Inpatient Care

目的：漏拔針是中醫醫療常見之危險事件，可能引起醫療糾紛、危及病人和醫護人員之安全，本研究之目的在於探討可能導致會診遺漏針之因素。方法：本次調查某南部醫學中心中醫部98年至105年病房會診之遺漏針事件，統計發生次數以及穴位、診斷等資料。結果：本研究發現遺漏針最常發生在上肢部位。發現者以病房護理師最多。發生月份以六月、八月、九月、十月為最多。最常發生遺漏針的穴位是百會、曲池、後谿及肩穴。發生遺漏針的患者以腦血管疾病的病人最多。結論：遺漏針較容易發生在容易被衣物、軀體、頭髮等物體擋住的地方，我們建議取針完後應再次搜索患者身體，由頭至腳依序搜索，檢查有無遺漏針之可能，尤其是容易遭視線擋住之處，是防止遺漏針發生十分重要的一個步驟，此外，改善職前教育品質、建立標準作業流程、確立多重確認機制、充分和病房醫療人員和患者溝通、定期召開檢討會議，以及考慮用固定出針人員或是不留針的治療方式，才能將遺漏針事件降至最低，以減少遺漏針事件。

Objective: Retained needles after acupuncture is a common adverse event after acupuncture. It may cause medical disputes and endanger the safety of patients and health practitioners. The present study aims to explore the location, timing, and diagnosis of retained needles after acupuncture. Methods: We counted the number of retained needles during January 1, 2009, to December 31, 2016, in a medical center in Tainan city, and analyzed the acupoints, primary diagnosis, persons who first discovered the failed removing needle, and occurred month. Results: The most common areas of retained needles events were the upper limbs. Most discoverers were a nurse. June, August, September, and October were the most common months of retained needles events. Above all the acupoints, most retained needles events occurred at DU20, LI11, SI3, LI15. Most of the events occurred in stroke patients. Conclusions: We suggest that improving the quality of pre-service education, establishing standard operating procedures and multiple confirmation mechanisms could reduce the incidence rate of retained needles after acupuncture. We also encourage health practitioners to maintain excellent communication with inpatients.