血管通路之病人安全異常事件：某區域醫院四年經驗分享

Vascular Access Safety Incident Reports in Regional Hospital: Four Years Experience

目的：管路事件是最常被通報的病人安全事件第三名。其中，血管通路事件包括血管滲漏，意外脫落或患者自行拔除，這在醫療環境中並不罕見。然而，它們很少在台灣病人安全通報系統中被報導。方法：為了解本院各種動靜脈管路意外事件發生情形，本研究審視2015年一月至2019年一月本院的病安通報資料。臨床回顧性研究統計分析了病人平均年齡、性別、入院原因、是否意識混亂、是否使用藥物、是否約束、發生地點、發生時間及導管名稱(中心靜脈導管、動脈導管、注射用人工血管、周邊置入之中心靜脈導管、透析用永久人工血管、雙腔靜脈導管、葉克膜導管、及心臟節律器導線等)和嚴重程度評估代碼。結果：血管內通路異常事件總共通報96件、病人年齡中位數70(標準差17.2)歲。男性占率62.5%。導管種類52(54.2%)件為中心靜脈導管、24(25.0%)件雙腔靜脈導管、及其他20(20.8%)件。最常通報是自己拔除(65.6%)及自己意外移除(22.9%)。病人自拔者最常發生在大夜時段(46.0%)，大多意識清楚(52.4%)。中心靜脈導管脫落後達53.8%經醫師評估改成周邊靜脈注射。血液透析的各式導管通報高達31例，其中93.5%是病人自拔或自己意外移除。異常事件嚴重度評估一級有6件(6.3%)、二級35件(36.5%)。嚴重度較高、管徑較大易造成失血的血管通路容易被通報。結論：以上研究建議，著重員工教育、加強訓練溝通、應落實組合式照顧盡早拔除中心靜脈導管，並以同理心面對蓄意自拔的病人，有助於建置更安全的血管照護。

Objectives. Access incidents are the third most common patient safety incident report. Vascular access incidents, including vascular leaks, accidental drop-off, or self-removal by patients, are commonly encountered in the acute healthcare settings. However, they are seldom reported in the Taiwan Patient Safety Report (TPR) System.
Methods. The cohort for this study was the vascular access incidents occurring in a regional general hospital and reported to the TPR system between January 2015 and January 2019.We retrospectively reviewed clinical findings and statistically analyzed the data, which included mean ages, gender, reasons for admission, levels of consciousness, medications, restrictions, locations, times, and types (central venous catheters, arterial catheters, Port-A, peripheral inserted central catheters, Permcath, double lumens, accesses of extracorporeal membrane oxygenation [ECMO], and wire of pacemakers) of vascular incidents, as well as severity assessment code (SAC).
Results. Totally 96 vascular access incidents were reported to TPR these four years. The mean age of victims was 70 (±17.2) years, with 62.5% incidents involving male patients. Fifty-two cases (54.2%) involved the use of central venous catheters, 24 (25.0%) double lumens, and 20 (20.8%) others. The more common causes of incidents were self-removal (65.6%) and accidental drop-off (22.9%). Patients with clear consciousness (52.4 %) tended to remove vascular accesses during midnight (46.0%). After the central venous catheters dropped off, 53.8% incidents could be resolved using peripheral venous catheters via evaluation. Thirty-one of the cases were on hemodialysis, and 93.5% of cases that happened due to purposeful or accidental self-removal. Six cases (6.3%) were in SAC-1 and 36 cases (36.5%) in SAC-2. Vascular access incidents with higher levels of SAC and larger vascular bores likely to cause blood loss were more often reported to TPR.
Conclusion. Patient safety can be improved by enhancing staff training, reinforcing communications, and implementing bundle care for central venous catheters as early as possible. Furthermore, healthcare workers need to be more empathetic with patients who try to remove catheters and their family members.