運用Time out概念建立加護單位移動病人安全作業

The Use of Time-Out as a Standard Safety Procedure for Transferring Patients in the Intensive Care Unit

加護單位為病人嚴重度最高、留置管路最多的特殊單位，在照護過程發生的風險相對提高，醫護人員於移動病人過程中發生管路滑脫事件，故成立專案小組進行改善。經查檢發現執行移動病人作業之正確率僅61.7%，分析確立問題為：缺乏移動病人風險概念及作業準則、缺乏教育訓練課程及監督機制、人員間未互相提醒說明及團隊合作不足。小組擬定對策有：訂定移動病人之安全作業準則、舉辦教育課程及拍攝教學影片以加強訓練移位技能、設計口訣及海報作為提醒、建立及強化品質監測機制與政策。於實施改善對策5個月後，執行移動病人安全作業正確率提升至100%，不僅提升移動病人的安全性，降低管路滑脫事件，也成功建立維護病人安全的團隊合作氛圍。

Patients with the highest severity or the most indwelling catheters usually remain in intensive care units (ICU), hence the risks of nursing care in the ICU are relatively high. Accidents such as catheter displacements often occur during the process of patient transferring; thus, the establishment of a special team to improve the quality of care is required. Only 61.7% of patient transferring processes are in accordance with the standard operating procedures (SOP), and possible challenges are as follows: 1. The lack of risk awareness and guidelines for patient transferring; 2. Insufficient training courses and surveillance; and 3. Poor teamwork. The countermeasures include establishing patient transferring SOP, providing training courses and educational videos to reinforce patient transferring techniques as well as designing catchy slogans and posters to develop, highlight and remind nursing personnel of the quality of secure actions and policies. Five months after interventions, patient transferring processes were in 100% accord with the SOP, namely the safety of patient transferring had increased, accidents of catheter displacement had decreased, and the teamwork milieu of safe patient transferring had been successfully established.