陳玉枝安全照護新.ppt

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筹忠董
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1 If pilots were doctors Adverse events 1 3.7% Due to errors 60% Adverse event % Permanent disability 13.7% Death 4.9% 51% preventable 1. Brennan TA..N Eng Med J 1991;324: Wilson RM. Med J Aust 1995;163: Bridging the Gap

6% Permanent disability 13.7% Death 4.9% 51% preventable 1.

2 : To Err is Human Building A Safer Health System Errors are caused by the bad systems; not by bad people (Danish Medical Association,2003) Error-Prone Situation Error-Prone Activities Error-prone People

3 A Formula for Errors System Design Good people + Bad System Hard to do the wrong thing Easy to do the right thing Quality is----- Doing the right thing right, right away

4 .. 1., 1., (JCAHO,2004)

5 ICU Eric Walter Walter Paul Eric Walter ( ) 40-50cc 50cc

6 () (,2002) PACK Patient and Pre- transfusion checks SHOT(Serious Hazards of Transfusion Steering Group) BCSH(British Committee for Standards in Haematology) PACK Checking and (Bradbury,2000) Clerical procedures PACK sepsis and Apparatus Keeping vigilant eeping accurate records

Standards in Haematology) 1999 1999 PACK Checking and (Bradbury,2000)

7 1 tab 1 tab tid tid" 1. U=units IU=International unit SC or SQ=Subcutaneous cc=cubic centimeters ss=sliding scale IU IV -q.d.q.i.d. Lanoxin Lanoxin q.i.d q.i.d q.d.(daily) q.d.(daily)

8 NOTE 2.0=2 q.d. q.d. daily daily 0.2=.2 2. &=and "&" /= " "(separates two "and" doses or indicates "per") "/" "1" ".2" "2" - 0 NOTE ER 0 mg (Cohen,1991) 3. mg=micrograms 4. AU=both ears AS=left ear AD=right ear 5. ) D/C=discharge;discontinue "mg"(milligrams) OU=both eyes OS=left eye ( OD=right eye discharge discontinue Lugol (OJ, Orange Juice)

9 目標三提高高危險藥物之用藥安全 NOTE ä 若醫師開立醫囑有標準縮寫或特 ä在護理單位不能放置高濃度的電解質製品包括濃度高的氯化鉀磷酸鉀別註明使用方法就不易看錯 ä 若護士瞭解Lugol s solution的作若護士瞭解Lugol solution的作用就不會把它當作眼藥水誤用氯化鈉等 ä對高濃度電解質的使用必須有標準化及領用限制的規定 Cohen (1991) ä高濃度藥品必須對劑量做管制應由藥房做監控劑量錯誤案例 -未仔細核對導致劑量過多急診室護士為肺栓塞病人注射heparin 急診室護士為肺栓塞病人注射heparin 10,000 unit ä 通常heparin 一瓶5 通常heparin 一瓶5 每１每１含 10,000unit 的藥全部抽取 10,000unit 但護士把5ml 但護士把5ml的藥全部抽取並為病人注射 ä 另一名護士發現heparin 的瓶子是空的這另一名護士發現heparin的瓶子是空的這時候才知道病人注射的是50,000unit 時候才知道病人注射的是50,000unit ä Cohen (1991) Demoral or Morphine?? NOTE 藥瓶標籤可清楚看到10,000 藥瓶標籤可清楚看到10,000 unit/ml unit/ml 卻在瓶身的另一處 ä 雖然護士會被責備但非所有的瓶籤都標示清楚除非藥商仔細的標示清楚否則使用者容易辨識錯誤 ä 準備這類藥物不要太急應仔細核對或規定由第二位護士或醫師做再次確認 ä 目標四避免部位錯誤病人錯誤及手術錯誤建立及實施手術前病人及部位確認的程序如應用勾選表 checklist 以確定紀序如應用勾選表 checklist 錄是否正確如藥物紀錄 ä 實施手術部分做記號的方法也請病人參與此步驟不僅是手術程序的確認也包括侵入性的治療程序如內視鏡檢查治療程序如內視鏡檢查 X光檢查等 ä Demoral Morphine 外觀相似容易混淆 9

另一名護士發現heparin 的瓶子是空的這另一名護士發現heparin的瓶子是空的這時候才知道病人注射的是50,000unit 時候才知道病人注射的是50,000unit ä Cohen (1991) Demoral or Morphine?

10 : Mr. Mr. Mr.Jenkins Mr.Jenkins Jenkins Jenkins X X X Jenkins Jenkins Jenkins Jenkins X X & & Jenkine Jenkine Jenkins Jenkins X X ( ( ) Jenkins enkins ( )

11 X Jenkins XX X (Reduce reliance on memory) (Improve information access) (Error-proof process) (Reduce the number of hand-offs) - macrodrip microdrip - macrodrip microdrip (aminophylline,40mg per hour) microdrip:60 drop/cc macrodrip:20 drop/cc macrodrip:20 drop/cc Cohen (1991) (aminophylline,40mg per hour) microdrip:60 drop/cc Cohen (1991)

microdrip (aminophylline,40mg per hour) microdrip:60 drop/cc macrodrip:20 drop/cc

12 NOTE I.V tube morphine I.V I.V The Swiss cheese model of accident causation The truth is

13 Working Together

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