提升神經外科加護病房護理人員資訊化交班完整性之改善專案

Improvement the Quality of Shift Hand-Off Process of Nursing Staff in Neurosurgical ICU

黃詩筑(Shih-Chu Huang)；曾莉晴(Li-Ching Tseng)；蘇虹頤(Hung-Yi Su)；江佩雯(Pei-Wen Chiang)

資訊交班 ； 交班完整 ； 病人安全 ； improve ； patient safety ； shift hand-off

志為護理-慈濟護理雜誌

22卷1期（2023 / 02 / 01）

71 - 82

繁體中文;英文

資訊交班的完整可讓接班者快速掌握重點並維護病人安全，達到持續的照護。因本單位交班內容有重複、遺漏及不確實以致交班耗時，引發其改善動機。探討資訊交班不完整因素有（一）傳統交班順序與資訊交班順序不同；（二）交班流程無統一規範；（三）資訊介面連結操作不熟悉；（四）等候資訊交班畫面時間過久；（五）臨床忙碌未即時記錄；（六）個人因素。經解決方案:規劃資訊交班在職教育訓練課程、創意設計交班安全口號，搭配簡易口訣交班流程等改善策略執行後，資訊交班完整率由59%提升至88.5%，達專案目的。期望此改善專案能提供臨床實務之應用，提升交班完整性及降低醫療錯誤發生。

Shift hand-off is a daily task that is done routinely. A thoroughly integrated shift handoff not only maintains patient's well being, but also sustains a high quality patient care. It had occurred in our nursing unit that duplicated records, missing content, and incorrect information were noted in the shift hand-off process. These factor had prolonged shift handoff time significantly. Analysis showed that the information during shift hand-off was only 59% accurate. Investigation indicated several elements causing this inefficient and inaccurate shift hand-off: (1) The mismatch of the information presented in a traditional (paper written) format with the electronic format; (2) No universal protocol ; (3) Unfamiliarity toward computer usage in accessing information; (4) Delayed computer processing time; (5) Inability to record patient data promptly due to busy clinical errand; and (6) Personal issues. The results of a literature review led to a specific "shift hand-off" process: (1) Providing a shift hand-off course during on the job orientation; (2) Establishing a creative" shift handoff" protocol; and (3) Integrating a simple" shift hand-off" slogan. After implementting our improvement program, effectiveness of shift hand-off improveed from 59% to 88.5%, which achieved our project objective. Having an efficient shift hand-off provides nursing staff with a focused picture of the patient and better patient care.

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