降低急診創傷性殘肢處理異常事件之改善專案

An Improvement Project to Reduce the Incidence of Abnormal Events of Handling of Traumatic Amputated Limbs at the Emergency Room

10.6692/KJN.202404_41(1).0004

陳雅慧(Ya-Hui Chen)；劉致如(Chih-ju Liu)；范巧怡(Chiao-Yi Fan)；楊純怡(Chun-Yi Yang)

Bundle處理包 ； 創傷性殘肢 ； 異常事件 ； Bundle Package ； Traumatic Amputated Limb ； replantation

高雄護理雜誌

41卷1期（2024 / 04 / 01）

47 - 60

繁體中文;英文

統計本院急診創傷性殘肢處理異常事件發生率竄升達3件，考量殘肢若處理不當，恐影響病人再植的機率，故引發改善動機。經分析確立問題：無殘肢處理標準作業流程、無明顯提醒機制、與接收單位沒有建立殘肢交班機制、殘肢包裹所需物品四散、無保冰裝置、醫護人員教育訓練不足。專案目的在急診創傷性殘肢異常件數降為0件／月。解決方法為制定殘肢處理標準作業流程、設計殘肢提醒卡及提醒牌夾、製作殘肢簽收卡、設置殘肢Bundle處理包、建置殘肢工作檯、設置殘肢專用保冰盒、舉辦殘肢處理教育訓練、設計殘肢處理流程海報及影片。改善結果異常件數由改善前3件降為0件，優化許多附加效益，使病人獲得完善的醫療品質，創造良好醫病關係。

According to the statistics, the error rate of handling traumatic amputated limbs (TAL) at the emergency room (ER) of our hospital was as high as three events. As inadequate handling of TAL may affect the success of replantation, our motivation to ameliorate the process was triggered. Analysis of the cause discovered: lack of standard operating procedures for the handling TAL, absence of obvious reminder mechanism, lack of handover verification for delivering TAL to receiving unit, scattering of items needed for TAL packaging, lack of ice storage device, and insufficient training of healthcare personnel. The purpose of the project is to decrease the error of handling TAL at the ER to zero event per month. The solutions included the establishing standard operating procedures for handling TAL, designing TAL reminder cards and receiving cards, designing TAL Bundle package, creating TAL workbench, creating special cooling box for TAL storage, implementing educational training for handling TAL, and propagating posters and videos of TAL handling process. As result, the number of error event decreased from three events before improvement to none. This project optimized the TAL handling process and brought many additional benefits, which enabled the patients to obtain high quality medical care and also improved doctor-patient relationship.

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