骨科手術後病人轉送病房電話交班之改善專案

The Project of Improving the Completeness of Postoperative Patients Shift Report with Telephone in the Orthopedic Ward

10.7078/TSMHMNJ.200806.0039

周佳諦(Chia-Di Chou)；鄭玉華(Yu-Hua Cheng)；游雅惠(Ya-Hui Yu)；朱桂香(Guey-Shiang Ju)；鄭淑華(Su-Hua Cheng)

手術後病人 ； 電話交班 ； 骨科病房 ； postoperative patient ； shift report with telephone ； orthopedic ward

東港安泰醫護雜誌

14卷1期（2008 / 06 / 01）

39 - 50

繁體中文

交班是護理臨床例行且重要的工作項目，也是維護病人安全中不可忽略的一環。本單位為骨科病房，約有九成的病人接受手術，因此本單位須經常與麻醉恢復室的護士做術後病人電話交班。本專案小組經由修訂交班標準流程、增加「手術後病人電話交班記錄」於病人交班單中、與麻醉科溝通協調交班相關事宜、製作電話交班指引卡、規劃交班在職教育課程、規劃骨科手術照護之雜誌討論會及實施電話交班稽核，使麻醉科與本單位之術後病人電話交班完整率由73.26%提升至96.41%，護理人員對手術後病人電話交班滿意度由改善前69.2%提升至86.6%，重要的是建立起單位間病人交接的標準化作業及跨單位間的溝通協調機制，以維護手術後病人安全。

Shift report is a daily and important routine work in clinical nursing and patient safty. There are almost 90% patients received operation in orthopedic ward. The orthopedic ward nurses need to get the postoperative patient data from post anesthesia recovery room nurses. We amend the process of shift report, design ｢the postoperative patient telephone report｣ in shift report, communicated the shift informations with post anesthesia recovery room nurses, develop the guideline card of shift report with telephone, arrange lectures about shift report practice, and evaluation of the report process. After completion of this project, the completion rate of the report increased from 73.26% to 96.41%, and the satisfactation of orthopedic ward nurses were increased from 69.2% to 86.6%. The most important thing is to establish the standard and communication between shift to shift reports and improve the postoperative patient safty.