降低透析室血液透析管路非預期滑脫率

Reduce the Unexpected Slippage Rate of Hemodialysis Tubing in Hemodialysis Room

血液透析管路任何連接點鬆脫會造成病人血液損失，嚴重導致失血性休克，本單位於2020年發生一件透析穿刺針滑脫事件，造成病人大量失血，歷經急救，最後死亡，專案小組成立目的為預防血液透析管路滑脫。現況分析歸納問題為護理端：未確實固定管路與查核管路、未落實管路安全衛教、未執行適當約束；病人端：對透析管路安全認知不足、皮膚不易黏貼紙膠；制度與設備：缺乏透析管路照護稽核制度、約束工具不符需求及衛生問題。經修訂動靜脈瘻管穿刺及移除作業指導書、血液透析作業指導書、舉辦管路安全工作坊、製作管路安全海報、創新手掌型約束帶等，維持對策實施八個月，透析管路滑脫發生為0件。本專案不僅降低透析管路滑脫，更強化病人對管路安全照護知識。

Any loose connection point of the hemodialysis circuit will cause the patient's blood loss, which can seriously lead to hemorrhagic shock. In 2020, a dialysis needle slipped off in our unit. The patient lost a lot of blood and finally died. The dialysis room set up a task force, and the purpose of the task force was to prevent hemodialysis tubing from slipping. The current situation analysis summarizes the problems as the nursing side: the pipeline is not fixed and checked, the pipeline safety education is not implemented, and appropriate constraints are not implemented; the patient side: insufficient awareness of the safety of the dialysis pipeline, and the skin is not easy to stick stickers; the system and equipment: lack of dialysis pipeline care audit system, restraint tools that do not meet the needs and hygiene problems. After revising the arteriovenous fistula puncture and removal operation instructions, hemodialysis operation instructions, holding pipeline safety workshops, making pipeline safety posters, innovative palm-shaped restraint belts, etc., the maintenance measures were implemented for eight months. There were 0 cases of dialysis tubing slippage. This project not only reduces slippage of dialysis tubing, but also strengthens patients' knowledge of tubing safety care.