手術器械配備包裝之改善方案

Project for Improving Surgical Instrument Kit Packaging

10.6142/VGHN.202212_39(4).0003

洪靖惇(Ching-Tun Hung)；潘靜雅(Ching-Ya Pan)；蔡美惠(Mei-Hui Tsai)；吳井于(Ching-Yu Wu)

器械 ； 配備 ； 病人安全 ； instrument ； packaging ； patient safety

榮總護理

39卷4期（2022 / 12 / 01）

353 - 360

繁體中文

當器械配備錯誤時不僅會延誤手術的進行，增加手術風險，甚至造成病人感染、死亡，專案前發現手術器械配備錯誤率為0.43％，自2018年9月1日至2019年4月30日進行改善方案，經現況分析發現導因有未遵守標準作業流程、查核制度不夠完善、未定期舉辦教育訓練、工作規範不夠完善等因素，予運用決策矩陣分析方法，將解決辦法分為政策方面－修訂標準作業流程、修訂工作規範及查核機制、定期舉辦教育訓練，人員方面－以「三到四指」提醒人員遵守標準作業流程，設備方面－修改器械明細單、單包器械刻印單一條碼、及將廠借器械轉為長駐本院器械等，使專案實施後，手術器械配備錯誤率降至0.082％，改善了手術器械配備之錯誤率，保障病人安全。

The purpose of this project was to improve the packaging of surgical instrument kits. Inappropriate instrument kit packaging engenders surgical delays, thus increasing the risk of patient infection or death. Before the implementation of this project, the error rate for surgical instrument kit packaging was 0.43%. The improvement project was implemented from September 1, 2018, to April 30, 2019. A review of the instrument kit packaging procedures revealed that the leading causes of packaging errors were noncompliance with standard operating procedures, flawed inspection systems, irregular training, and inappropriate regulation of working standards. Decision matrix analysis was used to formulate recommendations for improvement, which are outlined as follows: regarding policy recommendations, standard operating procedures should be amended and regular training programs should be organized; regarding personnel recommendations, managers should use ＂three to four fingers＂ to remind staff to comply with standard operating procedures; and regarding equipment recommendations, managers should develop an instrument list, engrave a unique barcode onto every instrument, and replace borrowed instruments with permanent instruments at the hospital. After the implementation of these recommendations, the error rate for surgical instrument kit packaging was reduced to 0.082%, demonstrating an improvement in ensuring patient safety.

1. 楊美雪、邱于平(2012)．圖像與文字的交織：網路知識分享形式對學習成效之影響．行銷評論，9(4)，463-475。
   連結：
2. Arora, S., Hull, L., Sevdalis, N., Tierney, T., Nestel, D., Woloshynowych, M., Darzi, A., & Kneebone, R. (2010). Factors compromising safety in surgery: Stressful events in the operating room. The American Journal of Surgery, 199(1), 60-65.
   連結：
3. Fang, Y., Shen, Z., Li, L., Cao, Y., Gu, L. Y., Gu, Q., Zhong, X. Q., Yu, C. H., & Li, Y. M. (2010). A study of the efficacy of bacterial biofilm cleanout for gastrointestinal endoscopes, World Journal of Gastroenterology: WFG, 16(8), 1019-1024.
   連結：
4. McNamara, S.A. (2011). Instrument readiness: An important link to patient safety. AORN Journal, 93(1), 160-164.
   連結：
5. 吳信宏、黃冠凱(2018)．重要的醫院品質管理系統參考指標-病人安全文化．品質月刊，54(3)，28-31。
6. 黃財明(2018)．標準作業程序SOP與查檢表之關連與運用．品質月刊，54(10)，24-29。
7. 衛生福利部台灣病人安全資訊網(2018)．病安作為-手術安全把關．http://www.patientsafety.mohw.gov.tw/Content/zMessagess/list.aspx?SiteID=1&MmmID=621273303476345677
8. 衛福部疾病管制署(2013)．滅菌監測之感染控制措施指引． https://www.cdc.gov.tw/File/Get/nrIxHDfOwi26QkNt07B0zA
9. Association for the Advancement of Medical Instrumentation. (2017). Comprehensive guide to steam sterilization and sterility assurance in health care facilities. Arlington: ANSI/AAMI ST79:2017.
10. Association of periOperative Registered Nurses. (2013). AORN Standards, recommended practices, and guidelines. Denver: AORN.
11. International Association of Healthcare Central Service Materiel Management. (2016). Central Service Technical Manual: Workbook (Spiral-bound)(8th Edition). IAHCSMM.