如何落实麻醉品质与安全PPT课件

如何落實麻醉品質與安全通報?醫療品質量測w透過臨床指標事件的定期監測，可以利用管制圖(Statistical Process Control)發掘醫療不良事件，以PDCA模式進行品質提升。w但許多醫療不良事件的發生極為少見，難以透過預先制定的指標加以監測。麻醉品質量測w麻醉品管指標系統w麻醉異常事件報告w麻醉重大併發症問卷調查量測系統麻醉品管指標麻醉品管指標麻醉異常事件麻醉異常事件麻醉重大併發症麻醉重大併發症ASA 麻醉品管指標wMortality(within 48 hours of anesthetic care)wOperation cancelled while receiving anesthetic care wDischarge/PACU Issues n 2 unplanned hours spent in PACU wAirway Problems nFailed tracheal intubation and unable to ventilate with mask nDental traumawCardiovascular Problems nCardiac arrest(during procedure or within 48 hours of anesthetic care)nMI(within 48 hours of anesthetic care)wRespiratory Problems nRe-intubation(within 48 hours of anesthetic care)nRespiratory arrest(within 48 hours of anesthetic care)nNon-cardiogenic pulmonary edema (within 48 hours of anesthetic care)nAspiration pneumonitis while receiving anesthetic care ASA 麻醉品管指標wRenal ProblemsnRenal insufficiency(within 48 hours of anesthetic care)nRenal failure(within 48 hours of anesthetic care)w Neurologic ProblemsnCVA(within 48 hours of anesthetic care)nPeripheral nerve deficit(within 48 hours of anesthetic care)w Regional Anesthesia Problems nFailed regional anesthesia nPostdural puncture headache wMedication Problems nMedication error(wrong medication given)nMedication dose error nAdverse drug reaction other than anaphylaxisnAnaphylaxis w Transfusion Reaction外部通報系統w台灣麻醉醫學會w年度麻醉重大併發症問卷調查w醫策會w台灣醫療品質指標計畫 TQIPTaiwan Quality Indicator Projectw台灣病人安全通報系統 TPRTaiwan Patient-safety Reporting Systemw麻醉事件通報（97年_月納入）麻醉重大併發症問卷調查w以年度為單位填報問卷，調查時易失真w內容不夠詳盡w無約束力，醫院配合度不夠w以outcome為主，無法提供具體改善品質建議台灣病人安全通報系統w不良(adverse)或跡近錯誤(near miss)事件n匿名、自願、保密、不究責、共同學習n個案呈現、整理後分享(Safety Alert)n外部通報：如何建立成功的通報系統?文化的改造w由上而下的領導，共同營造一個以病人為中心、不以懲罰個人為手段的麻醉醫療文化與環境好用及可信的平台w與醫策會合作，修訂現有 TPR 麻醉事件內容，透過醫策會的公信力，定期分享個案與資料回饋，讓值價呈現出來，使會員能持續安心通報，有效提昇麻醉醫療品質。麻醉事件通報w通報類型 13類(第五版)n麻醉事件n藥物事件、手術事件、輸血事件、管路事件、院內不預期心跳停止事件等w麻醉事件的定義n與麻醉過程相關之異常事件n麻醉誘導開始至術後24小時內通報途徑n個人通報、科內通報、院內通報？通報內容wA.通報事件資料wB.事件內容wC.此事件發生後的立即處理wD.您認為預防此類事件再發生的措施或方法wE.此類事件再次發生的可能情形wF.通報者資料麻醉事件內容-事件類型w插管相關 Intubation/induction-relatedw脊椎麻醉事件 SpinalAnaesthesia Eventw硬膜外麻醉事件 EpiduralAnesthesia event w鎮靜事件 Sedation eventw麻醉期間甦醒 Awareness during anesthesia w惡性高熱 Malignant Hyperthermiaw麻醉期間心跳停止 Arrest duringAnesthesiaw麻醉後心跳停止 Arrest Post Anesthesiaw手術中不適當之通氣/給氧 Inadequate intra-op ventilation/oxygenationw手術後不適當之通氣/給氧 Inadequate post-op ventilation/oxygenation w麻醉結束後無法甦醒 Failure to recover from anesthesiaw其他，請說明：麻醉事件內容-事件類型(修訂中)wNervous SystemnBrain death、Peripheral neurologic deficit(48 hrs)、Seizure、Stroke etc.wCardiovascular SystemnCardiac arrest、Cardiogenic shock、Myocardial ischemia etc.wAirwaynAirway injury、Difficult mask ventilation、Difficult intubation、Esophageal intubation、Re-intubation、Tracheal tube dislodgement etc.wPulmonary SystemnAsthmatic attack、Bronchospasm/laryngospasm、Pneumothorax、Pulmonary aspiration&edema、Pulmonary embolism etc.wMiscellaneousnAllergic reactions、Burn or electric shock、Injury/trauma、Equipment problems、Medication problems etc.如何落實麻醉品質與安全通報?廖熏香 組長 醫策會品質促進組第二段第二段