運用HFMEA手法提升呼吸器病人院內轉送檢查之安全性

Using HFMEA Tools to Improve the Safety of In-Hospital Transfer Inspection of Respirator Patients

本專案旨在運用失效模式與效應分析於加護病房呼吸器使用病人院內轉送安全分析小組成員討論並依據風險優先指數(RPN)，提出適當的預防措施及因應對策：修訂明確轉送作業規範、舉辦轉送教育訓練、明定呼吸器及監測器擺放位置、新設呼吸器病人氧氣耗用換算表、推動團隊間互相確認之轉送查檢作業，以及角色分工等安全防護機制與控制，並進行轉送改善措施評核。經以上改善措施，病人轉送異常件數發生率自65%低至23%，現場作業正確執行率由92%增加至98%，呼吸治療師自評滿意度平均分數由3.3分提高至4.2分，皆達到本專案設定之目標值。為達持續改善目的，未來將對加護病房呼吸器使用病人院內轉送安全評估，列為本科品質指標監測項目，特別是氣管內管滑脫及缺氧異常事件，將進行定期檢討與改善，必要時並進行案例檢討分析，凝聚團隊成員間對病人轉送的安全共識。

The purpose of this project was to apply the failure mode and effects analysis to the safety assessment of in-hospital transfer of patients wearing respirators in the ICU. After case discussion and a rough study of the risk priority number (RPN), the panel members proposed appropriate preventive measures and coping strategies for safety protection mechanism and safety control. These included, revising specific intra-hospital patient transfer regulations, holding transfer trainings, specifying locations to place the respirators and monitors, establishing an oxygen consumption conversion table for new patients, promoting interdepartmental communication among teams for intra-hospital patient transfer, and clearly defining roles. Outcome was accessed-by, follow-up evaluation of the measures corrected for each transfer. The rate of eventful patient transfers substantially reduced from 65% to 23% whereas the correct execution ratio of on-site operation increased from 92% to 98%. In addition, the average satisfaction score in the respiratory therapists’self-assessment rose from 3.3 points to 4.2 points. All project goals were achieved. To ensure continued improvement, the department’s quality index evaluation will include in-hospital transfer of patients wearing respirators in the ICU will be listed in the future, especially in the case of endotracheal extubation and oxygen deficit-related abnormality. Transfers will be periodically reviewed and improved. If required, case review and analysis will be conducted to strengthen the safety consensus among team members on patient transfers.