| 英文摘要 |
The project aims to apply team resource management to reduce the rate of herbal steam scalds occurred in acupuncture outpatients. Through the investigation, the causes of scalds were those patients not sensitive to heat. Besides, due to the insufficient knowledge, they shortened the distance of herbal steam and extended the treatment time against advice. Further, some nurses neither covered the steam caps tightly nor fixed the steam exporting part of the device. The steam bottle undertook boiled liquid did not have anti-heat facility, and steam exporting part of the device lacked an indentation, and probably the sticky steam particles of herbs caused blocking. By applying policy guidance and the team cooperation, we made the patients’ instruction of herbal steam treatment and paid more attention to staffs training. We also developed the steam bottle protector, and consulted the engineering team to develop a water droplet exit device with a measurement scale. Furthermore, we discussed with herbal pharmacy to improve the herbal solution and better quality control. The incidence of herbal steam scalds reduced from 5.1% to 0.2%, and the improvement was 96.1%. We hope that the mprovement experience by applying the team resource management project can be a reference for similar events. |
