運用團隊資源管理提升外科病房醫護團隊之訊息連結及值班滿意度

Apply Team Resource Management to Improve Surgical Ward of the Health Care Team Information Links and Watchkeeping Satisfaction

目的：病人辨識正確是檢查作業流程中重要的基礎，其檢查的結果會直接影響醫師診斷及處置的依據，若因過程中任何步驟失誤將影響病人的診斷與治療。方法：本專案改善是經由現況分析發現因病人辨識不正確，致檢查報告異常率0.16%及檢體標示錯誤率0.08%。故本專案目的為降低大腸鏡檢查病人辨識不正確率至0%。解決方案包括制訂大腸鏡檢查病人辨識作業規範、作業稽核表、大腸鏡檢查暫停確認檢核表並應用條碼科技於病人辨識作業流程及安排在職教育訓練。結果：經改善措施介入後，病人辨識不正確率降至0%，達成專案目的。結論：本文應用條碼科技導入大腸鏡檢查作業流程中，藉由暫停確認，確認病人的身分，增加病人辨識正確性之實務經驗分享，不但明確提升病人檢查過程的安全，也完成醫策會的病人安全目標，期盼作為其他侵入性檢查單位日後流程改造之參考依據，並提升檢查作業醫療品質。

Objectives: The identification of patients undergoing colonoscopic examinations is important with respect to work flow. The accuracy of patient identification provides an essential element to physician diagnosis and treatment. Indeed, incorrect patient identification will seriously affect the diagnosis and treatment of the patient, and increase health care costs. Method: Based on a retrospective analysis of the medical records in our unit, the incorrect patient identification rate was shown to be 0.16% and the specimen labeling error rate was 0.08%. The aim of this project was to reduce the incorrect patient recognition rate to 0%. The corrective solutions included the establishment of specifications for colonoscopy identification, a colonoscopy work flow check list, time out for confirmation, and application of barcode technology. Results: After importing the following instructions as proposed in this article, the incorrect identification rate was reduced to 0%; thus we reached the project goal. Conclusions: We increased the accuracy of patient identification by introducing bar code technology into the colonoscopy work flow. Not only did we promote security for patients undergoing colonoscopy, but we achieved the patient safety goal of the Taiwan Joint Commission on Hospital Accreditation. We have shared our relevant practical experience with others. We anticipate other invasive examination units will upgrade their medical quality by using our references.