降低外科加護病房胸管安全照護錯誤率

A Project to Reduce the Incomplete Rate of Chest Tube Safety Care in Surgical Intensive Care Unit

蘇筱雅(Siao-Ya Su)；彭淑敏(Shu-Min Peng)；彭千瑛(Chian-Ying Peng)；趙紀硯(Chi-Yen Chao)；王琬詳(Wan-Hsiang Wang)

胸管 ； 護理專案 ； 查檢表 ； check sheet ； chest tube ； nursing project

志為護理-慈濟護理雜誌

21卷2期（2022 / 04 / 01）

89 - 101

繁體中文

胸管為錯接率最高之管路類型，對病人健康影響皆為「重度以上」故引發動機改善胸管照護問題。運用查檢和訪談法進行問題收集及原因分析，確立問題為胸管安全照護錯誤率5.36%。經分析資料確認導因為：胸管作業規範不清楚、步驟繁瑣、護理人員照護認知不足及教學內容不完整。訂立目標為降低護理人員胸管安全照護錯誤率＜1%。解決辦法為：修訂胸管照護作業規範、設計檢視貼紙並舉辦在職教育、設計標準化教案等四項。胸管安全照護錯誤率由改善前5.36%降至改善後0%。本專案透過除錯法，簡化照護步驟及設計口訣，方便記憶，運用多元教學策略有效提升護理人員學習成效及照護能力，提升病人管路安全。

The project members triggered the motivation for improvement because chest tube has the highest misconnection rate within tube types, and the health effects on patients are at the ＂severe level＂. Using a check sheet and survey interview we found the incomplete rate of chest tube safety care was 5.36%. The project team members further analyzed the collected data and confirmed four causes: (1) insufficient understanding of chest tube specifications, (2) cumbersome steps, (3) insufficient awareness of nursing work, and (4) insufficient teaching content. The project aimed to reduce the incomplete rate of chest tube safety care by ＜1%. The solutions included: (1) revising the chest tube operation specifications, (2) designing inspection stickers and easy-to-remember mantras, (3) designing standardized teaching plans, and (4) holding chest tube in-service education. After the project, the incomplete rate decreased to 0%. We simplified the care steps and designed formulas through debugging techniques to facilitate memorization, and used multiple teaching strategies to effectively improve the learning effectiveness and care ability, and improve the safety of patient pipelines.

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