虛驚事件定義對呼吸治療師意外事件分類之影響

The Effect of Near-miss Definitions on Classifying Respiratory Therapist Incidents

王思惠

自我陳述的醫療事件 ； 虛驚事件 ； 瑞士乳酪模型 ； 病人安全 ； Self-reporting medical event ； near miss ； Swiss Cheese model ； patient safety.

長榮大學職業安全與衛生學系（所）學位論文

2016年

碩士

謝賢書

繁體中文

醫療本質即包含著不確定的因素，其來源包括儀器、設備、醫療人員的技能與團隊間的合作程度。處於高度緊急與忙碌的環境下，不管是無易的失手或瞬間的猶豫，醫療的疏失有可能造成異常事件，甚至危及到生命。本研究目的是期待呼吸治療師瞭解虛驚事件之定義，可即時清楚區分與提報，也藉由團體案例分享後，讓人員提升對於虛驚事件產生的警覺。除此之外，進一步有能力針對虛驚事件判斷其後果的可能嚴重程度，將有限的資源放在對嚴重程度高的虛驚事件之調查，以達到有效降低異常醫療事件產生。 研究方法採橫斷式設計與自擬結構式問卷，內容主要有呼吸治療師職場上之25題案例，透過參與焦點團體的醫療人員判斷何者為”虛驚事件”與”未造成傷害的異常事件”。第一次在無任何暗示下進行判斷；第二次先給予Reason瑞士乳酪模型的說明，再進行判斷。關於第二階段的自陳式虛驚事件提報，由同一批焦點團體自我提報過去一段時間之虛驚事件，接著讓參與進行分享，再提報一次。最後，由團體成員共同討論評估此25題案例的潛在後果嚴重程度。 問卷初始先依衛生福利部之”虛驚事件”名詞，針對呼吸治療師職場25題案例進行調查，第一次調查答對準確率為 69.6%；再由”Reason瑞士乳酪模型”重新定義”虛驚事件”名詞後進行第二次調查，答對準確率達 90.3%。最後藉焦點團體法，自我提報自身之”虛驚事件”發生次數，發現在團體討論分享後，工作環境或是日常生活無論是看到或發生”虛驚事件”之次數統計有明顯增加。針對呼吸治療師師職場25題案例中是屬於”虛驚事件”案例再進行辦別”可能產生嚴重傷害”的團體共識為62.5%。 研究過程中發現Reason瑞士乳酪模型的說明可使得”虛驚事件”的定義更簡易清楚。可使人員易於辨識醫療現場中發生的意外事件，並進一步分析何者屬可能產生嚴重傷害的事件，進而通報主管，改善相關的因素。藉由經驗的分享，資淺人員將可獲得更多經驗，映射於自我經驗中，當事件發生時立即自我辨識，是可以降低異常事件產生。

Objective : The nature of medical treatments is involved with many uncertain factors, which include physical instruments, facilities, human skills, and cooperation among team works. Any medical error, no matter which is slip or lapse arising in the intensive working atmosphere could cause abnormal events, even harm to a life. One way to reduce medical errors is the promotion of near miss reporting. One of the aims of this study is to investigate how the ways of defining near miss event and no harm event affect the accuracy of classification of these two kinds of events in near miss reporting. Another aim is to understand how much level of safety awareness can be lifted via group discussion of self-reporting medical events. The final aim is to differentiate the potential significance of near-miss event. The limited resources should be spent on investigating those events which could cause significant harm to reduce medical errors. Methods: In the first phase of this study adopts the cross-sectional approach with a structured questionnaire, which include 25 questions to be classified as either a near-miss event or a no-harm event by participants with/without the hint of the Swiss-Cheese model. In the second phase, the comparisons of the number of self-reporting medical events by medical staff are made between before and after a group discussion on the reported events. In the third phase, the set of 25 questions are discussed and scrutinized to reach consensus on their significance of potential harm. Results: In the first phase of the study, the correct classification with the hint of the Swiss Cheese model is 90.3% while it is 69.6% without the hint. In the second phase, after a group discussion on the reported events, the number of self-reporting events increases. And the consensus among the focus group is reached to determine that 62.5% of questionnaires are potential to cause significant harm. Conclusion: The application of the Swiss Cheese model help the participating medical staff correctly classify the medical events. The group discussion on the self-reporting medical events help improve the safety awareness among the participants and increase self-reporting cases.

1. 1. 中華民國呼吸治療師公會全國聯合會(2015) ・104年RT執登會員數・取自http://www.rtsroc.org.tw/affair/統計數據。
   連結：
2. 2. 周郁芳、葉淑娟、袁國書、張朝卿、游秋月、林慧真、陳彥澄 (2015)・探討不安全感與健康意識程度對健康預防行為之影響・台灣公共衛生雜誌，34(6) ， 605-615。DOI:10.6288/TJPH201534104007[Y.F., Chou, S.C.,Yeh, K.S., Yuan, A., Chang, C.Y., You, H.C., Lin, Y.C.Chen.(2015) Do You Feel Insecure? Influence of Health Consciousness on the Relationship between Existential Insecurity and Health Prevention. Taiwan Journal of Public Health,34(6), 605-615. DOI:10.6288/TJPH201534104007]
   連結：
3. 3. 林玲欽(2007)・護理人員的職業安全衛生知識、態度及行為相關因素之探討・(碩士論文)。取自http://handle.ncl.edu.tw/11296/ndltd/41909283720113927574[Lin, L.C.(2007) The analysis of the knowledge, attitude and behavior of occupational safety and health among nurse(master thesis). Retrieved from http://handle.ncl.edu.tw/11296/ndltd/41909283720113927574]
   連結：
4. 4. 侯勝茂、陳欣欣(2004)・提昇病人安全的新作為・臺灣醫學，8(4)，504-509。DOI： 10.6320/FJM.2004.8(4).07 [S. M., Hou, H. H., Chen.(2004) New Efforts in Promoting Patient Safety. Formosan Journal of Medicine,8(4), 504-509. DOI： 10.6320/FJM.2004.8(4).07]
   連結：
5. 5. 翁豊榮(2005)・醫療從業人員對醫院安全文化之認知・ (碩士論文)。取自http://handle.ncl.edu.tw/11296/ndltd/74208523779899238288[Weng, L.J(2005) The Perception of healthcare workers an hospital safety culture(master thesis). Retrieved from http://handle.ncl.edu.tw/11296/ndltd/74208523779899238288]
   連結：
6. 9. 梁惠玉、章淑娟 (2006)・醫護人員對醫療異常事件通報認知之探討・志為護理 (慈濟護理雜誌)，5(1)，88-97。取自http://www.airitilibrary.com/Publication/alDetailedMesh?DocID=16831624-200603-5-1-88-97-a [H.Y., Liang, S.C., Chang(2006) Physicians and Nurses Cognition Related to Medical Incident Report. Tzu Chi Nursing Journal,5(1), 88-97. Retrieved from http://www.airitilibrary.com/Publication/alDetailedMesh?DocID=16831624-200603-5-1-88-97-a]
   連結：
7. 11. 廖乾肇(2010)・安全領導與安全態度對安全行為影響的探討-以CCFL廠為例・(碩士論文)。取自http://handle.ncl.edu.tw/11296/ndltd/35977217050086630071[Liao, C.C.(2010) Safety leadership and Safety Attitude Affect Safety Behavior Study On CCFL Factory(master thesis). Retrieved from http://handle.ncl.edu.tw/11296/ndltd/35977217050086630071]
   連結：
8. 15. 財團法人醫院評鑑暨醫療品質策進會(2013)・醫療異常事件分類圖・取自 http://www.patientsafety.mohw.gov.tw/big5/default.asp# [ Joint Commission of Taiwan.(2013) Medical abnormal event classification map. Retrieved from http://www.patientsafety.mohw.gov.tw/big5/default.asp#]
   連結：
9. 16. Arnold, W. (1962). Discord and Collaboration: Essays on International Politics. Baltimore: Johns Hopkins Press.
   連結：
10. 18. Barach, P., Small, S. D. (2000). Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. Bmj, 320(7237), 759-763.
    連結：
11. 20. Callum, J. L., Kaplan, H. S., Merkley, L. L., Pinkerton, P. H., Rabin Fastman, B., Romans, R. A., Reis, M. D. (2001). Reporting of near‐miss events for transfusion medicine: improving transfusion safety. Transfusion, 41(10), 1204-1211.
    連結：
12. 21. Clarke, S. P., Rockett, J. L., Sloane, D. M., & Aiken, L. H. (2002). Organizational climate, staffing, and safety equipment as predictors of needlestick injuries and near-misses in hospital nurses. American Journal of Infection Control, 30(4), 207-216.
    連結：
13. 23. Heinrich HW (1959). Industrial accident prevention: a scientific approach (4th ed.). McGraw-Hill.
    連結：
14. 24. Institute for Safe Medication Practices(2009). ISMP survey helps define near miss and close call. Retrieved from https://www.ismp.org/newsletters/acutecare/articles/20090924.asp
    連結：
15. 25. Jones, S., Kirchsteiger, C., & Bjerke, W. (1999). The importance of near miss reporting to further improve safety performance. Journal of Loss Prevention in the process industries, 12(1), 59-67.
    連結：
16. 27. Reason, James (1997). Managing the risks of organizational accidents. Ashgate.
    連結：
17. 30. Wagner, L. M., Capezuti, E., & Ouslander, J. G. (2006). Reporting near-miss events in nursing homes. Nursing outlook, 54(2), 85-93.
    連結：
18. 6. 張春興 (1986)・心理學・台北市: 東華書局。[Chang C.H.(1986) Psychology. Taipei City, Taiwan, ROC:Tung Hua Book Co., Ltd.]
19. 7. 教育部重編國語辭典修訂本(2015)・安全 解釋・取自http://dict.revised.moe.edu.tw/cgi-bin/cbdic/gsweb.cgi[Ministry of Education, R.O.C.(2015) Safety Explanation . Retrieved from http://dict.revised.moe.edu.tw/cgi-bin/cbdic/gsweb.cgi]
20. 8. 教育部重編國語辭典修訂本(2015)・警覺 解釋・取自 http://dict.revised.moe.edu.tw/cgi-bin/cbdic/gsweb.cgi[Ministry of Education, R.O.C.(2015) Awareness Explanation . Retrieved from http://dict.revised.moe.edu.tw/cgi-bin/cbdic/gsweb.cgi]
21. 10. 黃首詠 (2006)・病人安全通報事件自動分類研究・(碩士論文)。取自http://handle.ncl.edu.tw/11296/ndltd/63579571591914357531[Huang, S.Y.(2006) Study of an Automatic Classification System for Patient Safety Reports (master thesis). Retrieved from http://handle.ncl.edu.tw/11296/ndltd/63579571591914357531]
22. 12. 維基百科(2016)・安全・取自https://zh.wikipedia.org/w/index.php?title=Special:%E5%BC%95%E7%94%A8%E6%AD%A4%E9%A1%B5%E9%9D%A2&page=%E5%AE%89%E5%85%A8&id=39361178[wikipedia(2016) Safety. Retrieved from https://zh.wikipedia.org/w/index.php?title=Special:%E5%BC%95%E7%94%A8%E6%AD%A4%E9%A1%B5%E9%9D%A2&page=%E5%AE%89%E5%85%A8&id=39361178]
23. 13. 維基百科(2013)・近似差錯・取自https://zh.wikipedia.org/w/index.php?title=%E8%BF%91%E4%BC%BC%E5%B7%AE%E9%94%99_(%E5%AE%89%E5%85%A8)&oldid=25510908[wikipedia(2013)Near-Miss. Retrieved from https://zh.wikipedia.org/w/index.php?title=%E8%BF%91%E4%BC%BC%E5%B7%AE%E9%94%99_(%E5%AE%89%E5%85%A8)&oldid=25510908]
24. 14. 謝賢書(2015，3月)・從自陳式虛驚與就醫次數比值探討組織的風險意識・第23屆海峽兩岸及香港澳門地區職業安全健康學術研討會。取自http://sites.cjcu.edu.tw/CJCUR/Handle.aspx?item=Conference&no=10452
25. 17. Aspden, P., Corrigan, J. M., Wolcott, J., & Erickson, S. M. (2004). Patient Safety: Achieving a New Standard for Care. Washington (DC): National Academies Press(US).
26. 19. Bird, F. E., & Loftus, R. G. (1976). Loss control management. Loganville, Ga. : Institute Press.
27. 22. Engel, J. F., Blackwell, R. D., & Miniard, P. W. (1995). Consumer behavior, 8th. New York: Dryder.
28. 26. Oktem, U. G. (2003). Near-miss: a tool for integrated safety, health, environmental and security management. Paper presented at the AIChE Proceedings of the 37th Annual Loss Prevention Symposium, New Orleans, LA, Spring.
29. 28. Robbins, S. P. (1992). Organizational Behavior-concepts, Controversies, and Applications (E. Cliffs Ed. 6th ed.). New Jersey Prentice Hill.
30. 29. Taylor, J. A., Brownstein, D., Christakis, D. A., Blackburn, S., Strandjord, T. P., Klein, E. J., & Shafii, J. (2004). Use of incident reports by physicians and nurses to document medical errors in pediatric patients. Pediatrics, 114(3), 729-735. Retrieved from http://pediatrics.aappublications.org/content/114/3/729.long