以流程再造降低慢性病房中醫針灸遺漏針發生率－某區域醫院為例

A Re-Engineering Method to Reduce the Missing Needle Rate at the Chronic Ward of Acupuncture Therapy-A Case Study in a Regional Hospital

10.6516/TJTCM.202003_23(1).0004

佘素蓉(Su-June She)；呂友文(Yu-Wen Lu)；蔣嘉鈴(Chia-Ling Chiang)；陳妤晴(Yu-Ching Chen)；李合幼(Ho-Yu Lee)；劉淑浚(Shu-Chun Liu)

針灸 ； 病人安全 ； 流程再造 ； 團隊資源管理 ； acupuncture ； the safety of patients ； process re-engineering ； team resource management

中醫藥研究論叢

23卷1期（2020 / 03 / 30）

45 - 56

繁體中文

世界衛生組織（WHO）提出六十四種針灸適應症，顯示針灸在國際受到重視及普遍運用於各種疾病替代療法之一。針灸治療過程中遺漏針為最常見的異常事件，且容易造成針扎事件，危害醫護人員安全及病人安全，如何降低針灸遺漏針發生是非常重要的。本研究動機為某區域醫院慢性病房之針灸遺漏針發生率高達0.96%，其中2例滯針造成醫護人員針扎，盼透過本研究找出原因改善遺漏針發生率。首先針對病房針灸流程進行分析，召開會議運用腦力激盪、現場觀察法、會談法、問卷調查、查閱病歷、針灸安全認知測驗法進行現況分析，發現問題在於未確實填寫中醫醫囑單、對針灸處置不熟悉、未明訂針灸標準作業流程、未有針具收集盒及治療中告示牌；找出問題後，依可行性、效益性、重要性及經濟性等四項進行評價指標，進行決策矩陣分析確認改善方式，透過團隊資源管理（TRM）運作，以流程再造修訂針灸標準作業、中醫醫囑單、執行Time Out對針、固定中醫師神手時間、翻轉教學在職訓練、執行縫針計數固定器、設置告示牌等方案介入；流程再造前遺漏針發生率0.96%，實施流程再造後發生率降至0%成效顯著，相信可解決針灸遺漏針問題，增進醫護人員與病人安全，提升照護品質，期望可作為日後醫院照護針灸治療之參考。

World Health Organization (WHO) declared 64 acupuncture indications, showing that acupuncture has become much more valued and popular internationally as one of alternative therapies. The most common incident of acupuncture is the event of missing needle which is prone to cause needlestick injuries and damage the safety of medical workers and patients. Reducing the incident of missing needle is crucial for safety. This study aimed to investigate the causes of high missing needle rate (up to 0.96%) in the chronic ward of a regional hospital, among which there were 2 cases resulting in retained needle in patient's back and needlestick injuries of medical staff, and to find a way to improve it. The acupuncture procedures in the ward were analyzed through brainstorming, field observations, interviews, questionnaire survey, medical chart review and acupuncture safety examination, etc. Problems were identified including ineffective implementation of Chinese Medicine prescriptions, unfamiliar with acupuncture treatment, no well-defined acupuncture SOP, no acupuncture needle disposal container, and no sign or display indicating under treatment. Improvement strategies were formulated through 4 evaluating indicators: feasibility, benefit, importance, & economical efficiency. With Team Resource Management (TRM), a re-engineering process was conducted to revise the acupuncture SOP and Chinese Medicine prescription form and implement needling check while time out, fixed needling time, on job training of flipped teaching, hook calculator and sign installation. After the implementation of the countermeasures, the missing needle rate dropped from 0.96% to 0%. The significant improvement shown in the study is believed to be a framework for reference to solve the problem of the missing needle, which could assure the safety of medical workers and patients and improve the healthcare quality.

1. 江惠英(2015)。再談團隊資源管理。領導護理，16(4)，2-10。
   連結：
2. 黃珊,陳順宇,陳淑華(2015)。建構手術室病人安全照護作業模式─以手術病人辨識、部位、程序安全為例。健康科技期刊，3(1)，52-67。
   連結：
3. 顏素美,龔佩珍,葉麗月,黃宣穎,蔡文正(2016)。探討中醫師對針灸治療病人安全之認知、態度及預防措施。醫學與健康期刊，5(1)，35-51。
   連結：
4. He, W.(2012).Adverse events following acupuncture: a systematic review of the Chinese literature for the years 1956-2010.J Altern Complement Med,18(10),892-901.
5. Rothrock, J.C.(2014).Alexander’s Care of the Patient in Surgery.台灣:台灣愛思唯爾.
6. Stanton, C.(2015).Improving team engagement during the time out.AORN J,101(6),7-9.
7. Wu, J.(2015).Systematic Review of Adverse Effects: A Further Step towards Modernization of Acupuncture in China.Evid Based Complement Alternat Med,2015,432467.
8. Zhang, J.(2010).Acupuncture-related adverse events: a systematic review of the Chinese literature.Bull World Health Organ,88(12),915-921C.
9. 卓雨青(2016)。針扎事件處理原則。首都中醫報導，30，13-15。
10. 林雅玲,歐淑玉,陳玲珠,陳繼鳳(2012)。中醫針灸處置遺漏針之改善專案。中西醫結合護理雜誌，2，67-75。
11. 徐盈真,蘇佩真,莊琇雯,陳亞玲,陳幼梅(2016)。運用 Time out 概念建立加護單位移動病人安全作業。高雄護理雜誌，33(1)，19-30。
12. 張恒嘉(2013)。活用 TRM 團隊好溝通。志為護理－慈濟護理雜誌，12(6)，26-29。
13. 鄒芊柔,張文馨(2017)。運用團隊資源管理落實於手術病人安全之經驗。醫療品質雜誌，11(1)，57-63。
14. 趙華,米勇,馬忠(2007)。針灸操作記錄規範化探索。新疆中醫藥，25(4)，58-59。
15. 衛生福利部：106 年中醫門診總額整體性醫療品質資訊公開報。2018。
16. 衛生福利部：民國104年醫療統計年報。2015。