改善血液透析機警報發生之專案 - tnna.org.tw
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改善血液透析機警報發生之專案
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關鍵詞：血液透析、透析機、警報、護理、專案
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99 3 5 99 7 15 100 5 13
70170 80
08 7624002 558 [email protected]
Yang, Hwang, &
Taiwan Society of Nephrology, 2008
2008
Joint Commission on
Accreditation of Healthcare Organization,
JCAHO 2003
2 0 0 6 J C A H O ,
2009
Phillips &
Barnsteiner, 2005
2
100 12 10 3
4 54
2008 1~6
2,897
568 37
5.7 1
12 32 1 4
TORAY-321 14
NIKKISO-26 6 NIKKISO-27 34
TORAY-321
7~8
NIKKISO-26 -27
2008 6 9
7 14 3
6
6
12
2,582
215
2008 6
2,896
79
2.7
2008 6 129
35 27
2008 7
18 7 25 37
3
100 12 10 3
27 73
4
2008 6
56 43
18
48
32 86
1. 1-1 52 2 78 3
1-2 26 1
2. 2-1 413 4 516 20
2-2 103 16
3. 3-1 129 5
3-2 ( ) 155 6 465 18
3-3 181 7
4. 4-1 103 4 129 5
4-2 26 1
5. 5-1 181 7 258 10
5-2 77 3
6. 6-1 439 17
6-2 310 12
6-3 129 5 1136 44
6-4 52 2
6-5 129 5
6-6 77 3
4
100 12 10 3
12 32
18 48
A B
22 59
33 89
NIKKISO-27
NIKKISO-26
26 70
12 32
2008 7 28 7 30
37
80 25 68
80 12 32
23
62
8 1 7 37
81
74 73
77
7~8
5
100 12 10 3
3 2008 8
8
15 3
45
215 118
2 1 5
215 45
2008 NIKKISO, 2006 Phillips &
Barnsteiner, 2005
2008 Phillips &
Barnsteiner, 2005
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100 12 10 3
2008
2008
2008
2 0 0 3
Zeigler, 2007
2003 Bitan, Meyer, Shiner, &
Zomora, 2004
2007
2008 NIKKISO, 2006
2006
2006 Zeigler,
2007
2008
2008
2007
2008 Phillips & Barnsteiner,
2005 Zeigler, 2007
NIKKISO, 2006
2 0 0 8 2 0 0 6
NIKKISO, 2006
7
100 12 10 3
3 2008 8 10
5
1
2008 8 16 2009
2
2008 8 16 ~2008
10 31
8 16
11 8~9
8 17
(a)
150 1
8 20~21
4 62
8 22~23 4
62
100
59
31
51.9
28 48.1 8
29
(b)
(c) 9 10~11
62
2008 9 5
8
100 12 10 3
1. 15 12 14 12 53
2. 12 3 10 10 35
3. 15 15 14 15 59
4. 8 15 8 8 39
5. 10 5 12 5 32
6. 13 12 15 13 53
7. 6 12 6 11 35
8. 15 15 13 15 58
9. 15 15 15 14 59
10. 9 5 5 10 29
11. 5 9 5 9 28
12. 15 15 15 12 57
13. 5 10 5 6 26
60 5 3 4
2008 2009
8 9 10 11 12 1 2
16 01 16 01 16 01 16 01 16 01 16 01 16
31 15 30 15 31 15 30 15 31 15 31 15 28
1.
2.
3.
4.
5.
6.
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~10 15 52
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10 16
2008 10 16 ~2009
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24
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100
2008 11 8~9
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18~20
2008 11 1 ~2009 1 15
12 21
2009 1 16 ~2009
2 28
2009 1 16
~2 15
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2009 1 16 ~18
37
2009 2
2009 1
2009 1 16
~2 15 12
6
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100 46
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2009 2
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118
Hawthorne Effect
10
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2009 1
16~18 37
87 94
2008 2 1~7
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11
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1. 1-1 52 23
1-2 26 16
2. 2-1 103 56
2-2 413 276
3. 3-1 129 53
3-2 55 81
3-3 181 86
4. 4-1 103 54
4-2 26 14
5. 5-1 181 87
5-2 77 48
6. 6-1 439 229
6-2 310 152
6-3 129 48
6-4 52 36
6-5 129 87
6-6 77 46
2582 1392
76 94
90
2009 1 2,782
79 2.7
56 2.0
12
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N=37
81 92
74 95
73 93
77 94
N=37
75~80 12 32 0 0
85~90 16 43 0 0
90~95 4 11 15 41
95~100 5 14 22 59
2006
2008 3 3
2010 4 21
http://www.ylh.ntuh.mc.ntu.edu.tw
/ylh/paper/96/9601/960303.php
2006 12 26
2010 4 21
http://www.doh.gov.tw/
CHT2006/DM/SEARCH_RESULT.aspx
2007 DBB-26
28 4 85
2008
29 12 123-124
2008 9 28
2008 10 18
http://www.greencross.org.tw/dialysis
/HD_ echanism/dialyzer.htm
2003
2 1 70-76
2008
5 9
2008 10 18
http://www.kmuh.org.tw/www/
Administration/patient_safe/index.html
2008
7 1 12-25
Bitan, Y., Meyer, J., Shiner, D., & Zmora,
E. (2004). Nurses’ reactions to alarms
in neonatal intensive care unit.
Cognition Technology & Work, 6(4),
239-246.
Joint Commission on Accreditation of
Healthcare Organization. (2009, Dec
17). Patient safety-related standards.
Retrieved April 20, 2010, from
http://www.premierinc.com/quality-
safety/tools-services/safety/topics/
patient_safety/index_3.jsp#new%20p
atient%20safety%20standards
Phillips, J., & Barnsteiner, J. H. (2005).
Clinical alarms: Improving efficiency
and effectiveness. Critical Care
Nursing Quarterly, 28(4), 317-323.
NIKKISO (2006). Hemodialysis system:
DBB-27 operating instruction manual
Ver. 2.0. Japan: NIKKISO.
Yang, W. C., Hwang, S. J., & Taiwan
Society of Nephrology. (2008).
Incidence, prevalence and mortality
trends of dialysis end-stage renal
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The impact of national health
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hemodialysis catheter disconnections.
Nursing, 37(3), 70.
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Project for Dialysis Machine Alarm Improvement
Mu-Hsin Wang Chun-Man Hsieh* Wan-San Chiang
Abstract
Patient safety relies on the normal operation of the dialysis machine. Frequent alarms
caused by equipment malfunction can affect patient health. Our investigations found that up
to 215 alarms were triggered per shift. Causes included: no user manual for the new dialysis
machine, equipment shortages such as the arm fixer/warmer and blood vessel trend chart;
nurses’ lack of caution, knowledge and skill on dialysis operations; a lack of continuing
education on dialysis machine operation and no monitoring mechanism for standard dialysis
procedures.
The purpose of this project was to reduce the frequency of machine alarm to less than
118 per shift. Solutions included: Compiling a user manual for the dialysis machine;
installing additional arm fixers/warmers and including the blood vessel trend chart on the
patient’s chart; setting up an incentive scheme; as well as provide continuing education and
regular monitoring of dialysis procedures. After the improvements were made the frequency
of machine alarms decreased to 116 per shift. This project has been a success and provides a
reference for improvements to dialysis machine alarms in other units.
Key words: hemodialysis, dialysis machine, alarms, nursing, project
RN, Hemodialysis Room, Department of Nursing, Chi Mei Medical Center
RN, MSN, Instructor, Department of Nursing, Tajen University and Doctoral Student, Institute of Medical
Sciences, Tzu-Chi University*
Received Mar. 5, 2010 Revised Jul. 15, 2010 Accepted for publication May. 13, 2011
Correspondence Chun-Man Hsieh, No.80, Wen-Dung St., Tainan 70170, Taiwan, ROC.
Telephone 08 7624002 ext 558 E-mail [email protected]