建立病患安全查核表及查核方法成效評值

Implementation and Effectiveness Evaluation of Patient's Safety Checklist and Check Method

10.29494/LN.200706.0004

杜異珍；朱月英；夏珊；廖淑媛；戴定玲；汪湘雲；汪乃玲

病患安全 ； 病患安全查核表 ； 查核方法 ； 成效評值 ； Patient safety ； Patient safety checklist ； Check method ； Effectiveness evaluation

領導護理

8卷1期（2007 / 06 / 01）

27 - 41

繁體中文

本專案旨在建立病患安全查核表及查核辦法，及時更正不合標準之流程及管理，提升護理人員對病患安全的認知及重視，進而提升病患安全。專案之執行，係先由護理部安全組成立查核小組，依原使用中之查核表，新增及修訂部分查核內容，經專家效度及試用再修正後，完成適用之病人安全查核表。設訂各查核項目之目標值爲100（%•分），閾值爲95（%、分）。改善前查核結果：發現8項查核項目皆未達閾值95（%、分），依特性要因圖分析，主要問題爲護理人員缺乏警覺性、認知不足、未重視病患辨識之重要性、病患因素（不願配合）、病房行政負責人未重視、病患安全查核細則不完備、未訂定查核標準、藥品標示不清楚及未分開管理等。因而於行政會議中宣導病患安全之重要性，舉辦在職教育、研習會及標竿學習，檢視修訂病患安全手冊內涵，製訂查核辦法，定期每個月由專案查核小組查核各病房，並回報給各病房，針對未達閾值者，要求行政負責人以書面回復未達閾值原因及改善辦法，並列爲績效考核項目，來提升護理人員對病患安全之認知及重視，並提升病患安全。專案小組持續不斷的監督及查核4個月，8項查核項目皆已達閾值，其中病患辨識已達目標值100%。顯示經由專案的查核及監測，透過行政結構，確能有效的改善提升護理人員對病患安全的認知及重視、提供安全優質的照護保障病患權益。

The purposes of this project were to implement the appropriate patient safety checklist, correct the non-standardized check processes and their management in time, and improve the nurses' awareness and care for patient's safety. The implementation process started in the safety group of the Nursing. Department with modifying patient safety checklist, which was examined for its validity by an expert pannel. The target values of all checked items were 100 (%、score) and the passing values 95 (%、score). Eight items didn't pass the examination values prior to the project. Based on the Fishbone Diagram, the causes were identified as: lack of alertness, fail to inadequate recognize and care for the patient's feeling and safety, patient's exhibit negative behaviors (refuse to cooperate, refuse to sleep, etc), inadequate check details, lack of check standards, medicine with unclear tags, and medicine did not get non- separately. Thereafter, the importance of the patient safety was repeatedly emphasized in the administration meeting. On the job training and seminars were provided. Manuals of patient safety check were examined and properly amended. Performance audit methods were set up and all the wards were inspected monthly by the project audit group members, and the results were forwarded to the wards. The nurses in charge of the cases that didn't achieve the passing values were asked to explain the causes and to give interventions for improvement. The feedback was expected to enhance their awareness and care for the patient's safety. After evaluation was perfored continuously. Eight check items had achieved the passing values and the patient safety recognization values had achieved the target values completely.