雙重警報止血帶：提升病人安全的創新設計與應用

Dual-Alert Tourniquet: An Innovative Design and Application for Enhancing Patient Safety

本研究旨在改善臨床止血加壓帶使用過程中因遺忘移除所造成之病人安全風險。止血加壓帶若未於適當時間移除，可能因長時間壓迫導致皮膚壓傷、組織壞死或血栓形成等併發症，進而增加醫療照護成本與病人安全事件發生風險。為降低此類可預防之臨床疏失，本研究開發具備視覺發光與聲音提醒功能之雙重警報止血帶，將提醒機制直接整合於止血加壓帶本體，以提升臨床人員對止血帶使用狀態之覺察。本研究採用品質改善之前後比較設計，於北部某醫學中心心血管重症加護病房導入臨床使用，以30名實際使用止血加壓帶之護理人員為介入對象，並以止血加壓帶未移除之病人安全事件及護理人員使用滿意度作為成效評估指標。結果顯示，介入前共發生3件止血加壓帶未移除之病人安全事件，異常發生率約為0.23%；導入雙重警報止血帶後，觀察期間未再發生相關事件，異常發生率降為0%。此外，研究期間未出現病人不適、皮膚過敏或器材脫落等情形。護理人員於提醒效果、操作便利性及臨床實用性之平均評分皆高於4.6分。研究結果顯示，雙重警報止血帶可有效降低人因疏失風險，提升病人安全與照護品質，並具備低成本、流程內嵌及跨單位推廣應用之潛力。

Failure to remove a tourniquet in a timely manner may result in prolonged tissue compression, leading to pressure injuries, tissue necrosis, thrombosis, and other preventable patient safety events. To address this clinical safety concern, this study developed and evaluated the Dual-Alert Tourniquet, an innovative device designed to reduce omission-related errors associated with forgotten tourniquet removal. The device incorporates both visual illumination and auditory reminder functions, embedding a real-time alert mechanism directly into the tourniquet to reduce reliance on human memory during routine clinical practice. A before-and-after quality improvement study was conducted in the cardiovascular intensive care unit of a tertiary medical center in northern Taiwan. Thirty nurses who routinely performed procedures requiring tourniquet application participated in the intervention. The effectiveness of the intervention was evaluated using patient safety incident reports and user satisfaction surveys. Outcomes included the occurrence of unremoved tourniquet events and healthcare professionals’satisfaction with the device. Prior to implementation, three incidents of forgotten tourniquet removal were reported, corresponding to an event rate of approximately 0.23%. Following implementation of the Dual-Alert Tourniquet, no further incidents were reported during the observation period, resulting in a reduction of the event rate to zero. No device-related adverse events, including patient discomfort, skin irritation, or device detachment, were observed. In addition, mean satisfaction scores for reminder effectiveness, ease of use, and clinical applicability were all greater than 4.6 on a 5-point Likert scale, indicating high user acceptance. These findings suggest that integrating reminder mechanisms directly into routinely used clinical devices may effectively reduce human-factor-related omissions and enhance patient safety. As a low-cost, workflow-integrated patient safety intervention, the Dual-Alert Tourniquet demonstrates promising potential for broader implementation across diverse healthcare settings.