恢復室轉送員執行術後病人轉送安全之改善專案

A Program to Promote Safety of Transferring Patients in Post-Anesthesia Care Unit

手術後恢復之病人具有科別複雜、疾病嚴重度高的特性，需依據病人嚴重度進行轉送，確保術後病人轉送安全。本專案旨在提升恢復室術後病人轉送安全，調查發現：轉送員在轉送安全正確率及認知分別僅有68.4%及51%，原因為：手術室出入口動線調整使轉送作業流程變更、工作細則缺乏轉送安全內容、轉送員皆對轉送安全注意事項不了解認知不足、缺乏可稽核轉送安全的工具。經專案小組擬定改善方案包括：(1) 電動轉運床動線調整；(2) 修訂「恢復室轉送員工作細則」；(3) 舉辦轉送員在職教育；(4) 制訂轉送標準作業流程；(5) 設計轉送安全口訣；(6) 制訂轉送安全查核機制的工具。結果顯示轉送安全執行正確率由68.4% 提升至91.7%，認知由51% 提升至87.9%。而轉送員是病人轉送服務中重要的角色，透過舉辦在職教育與轉送安全作業流程標準化來促進安全，讓轉送過程順暢與正確，提升術後轉送病人安全與醫療品質。

It is imperative to provide safe transferring for patients in post-anesthesia care unit (PACU), considering the complexity of specialty and patient’s high acuity. The purpose of this program was to promote the safety of transferring of patient in PACU. The team members found out that accuracy rate and recognition rate of transfer personnel were 68.4% and 51.0%, respectively. The reasons were as the following: the change of patient transferring operation procedure due to change of entrance and exit in the operating room, lack of contents on job description, and improper safety transfer due to lack of knowledge and monitoring tool. Six resolution methods were executed as the following: (1) adjusting route of moving electrical beds, (2) revising job description for transfer personnel, (3) providing continued education for transfer personnel, (4) establishing an operation procedure on patient transfer, (5) designing mnemonic phrases for remembering, and (6) formulating monitoring mechanism on safety transfer. The results revealed that both accuracy rate and recognition rate improved from 68.4% to 91.7% and from 51% to 87.9%, respectively. Since transfer personnel play important roles in patient transfer, a program including continuing education and standardized operation procedure were implemented to promote safety and quality in transferring patients.