運用品管圈手法降低精神護理之家住民異物哽塞率改善專案

Use of Quality Control Circle Technique to Reduce Choking on a Foreign Body in a Psychiatric Nursing Home

精神科病人哽塞，嚴重危害病人生命安全，甚至造成醫療糾紛，依據2016年台灣病人安全通報系統(Taiwan patient safety reporting system, TPR)資料顯示，精神科醫療照護事件，因食物或異物哽塞導致急救事故之事件共有33件(3.9件/百件)。2016年3月至2017年3月本精神護理之家發生異物哽塞件數為7件，導致死亡3件，致死率為42.9%，分析哽塞原因為：1.住民進食能力受限及認知不足、2.預防異物哽塞作業標準不適用、3.家屬認知不足、4.工作人員認知不足。運用QCC手法改善異物哽塞發生率，以PDCA模式推行四大方案：1.執行住民健口運動、2.修訂預防異物哽塞作業標準、3.訓練輔助復健學員、4.進行護理人員及照服員在職教育，經過實施改善專案後，住民異物哽塞發生率降至0%，達成專案目標，藉由專案降低異物哽塞發生進而提升住民安全與生活品質。

When psychiatric patients choke of foreign bodies, their lives can be put in danger and medical disputes may arise. According to 2016 Taiwan patient safety reporting system (TPR) data, 33 incidents (3.9/100) of psychiatric medical emergency care events were caused by food or foreign body obstruction in the esophagus. In our nursing home, there were seven, three resulting in death (42.9%) from March 2016 to March 2017. The reported reasons for these choking events were there were limitations in the resident’s eating and cognition ability, no protocol was followed to prevent choking, family members were unaware of the problem, and there was insufficient staff awareness. We used the Quality Control Circle (QCC) technique to reduce incidence of foreign body obstruction and PDCA model to (1) improve the residents' health movement, (2) revise standards for preventing foreign body obstruction, (3) train assisted-rehabilitation students and nursing staff, and (4) give caregiving staff members in-service education. After implementation, the incidence of foreign body obstruction decreased to 0% with no reported foreign body obstructions as of June 30 2018, and thus our goal was achieved. Implementation of this project, reduced the rate of foreign body obstruction and improved safety and quality of life among our nursing home residents.