麻醉品质管理之经验~改善患者於手术室内手术被取消(2009年07月18日).ppt

2019/9/17,1,麻醉品質管理之經驗 改善患者於手術室內手術被取消 (2009年07月18日),中山醫學大學附設醫院麻醉科主治醫師劉漢傑,2019/9/17,2,2009年台灣麻醉品質與安全研討會,Reports of the Institute of Medicine (IOM),The U.S. health care system performs far below obtainable levels of patient safety and overall customer values. The 1999 IOM report estimated that 44,000 to 98,000 Americans die each year as a result of medical errors. (Effective Clinical Practice, November/December 2000.),2019/9/17,3,2009年台灣麻醉品質與安全研討會,Reports of Harvard University,RAND researchers found that 3% of U.S. inpatients experience avoidable harm and that opportunities for significant improvement in patient functional status are missed in 11% of chronically ill outpatients.,2019/9/17,4,2009年台灣麻醉品質與安全研討會,Total number of cases = 67 (100%) * One young patient showed type II of a second degree atrioventricular block on the EKG monitor in the OT, one young male needed further surgical work up after the anesthesia was given.,2019/9/17,5,2009年台灣麻醉品質與安全研討會,Table 2-Classification of persons who postponed or cancelled the Surgery,Total number of cases = 67 (100%) Board letters indicate the sum of the related items. * The patients family cancelled the surgery because of insurance problems.,2019/9/17,6,2009年台灣麻醉品質與安全研討會,Table 3-Categories of Patients Surgeries Postponed or Cancelled inside the Operating Theater,2019/9/17,7,Table 3a-Categories of Patients Surgeries Postponed or Cancelled inside the Operating Theater,Total number of cases = 67 (100%) Fever (1), change in neurological condition (1), hypoglycemia (1). No fasting (1), the patient or family wanted to cancel the surgery when the patient was in the operating theater (2), insurance problems (2), poor communication between caregivers (2).,2019/9/17,8,2009年台灣麻醉品質與安全研討會,Table 4-Surgical results of Patients after their Surgeries were Postponed or Cancelled,Total number of cases = 67 (100%) . * Surgery was no longer needed (2), cardiovascular accident 2 months later (1), surgery was performed 1 year later (1). * Patient expired after surgery was cancelled: range 1 day-20 days, mean 12.7 days.,2019/9/17,9,2009年台灣麻醉品質與安全研討會,Table 4a -Surgical results of Patients after their Surgeries were Postponed or Cancelled,Total number of cases = 67 (100%) * Surgery was no longer needed (2), cardiovascular accident 2 months later (1), surgery was performed 1 year later (1). * Patient expired after surgery was cancelled: range 1 day-20 days, mean 12.7 days.,2019/9/17,10,2009年台灣麻醉品質與安全研討會,The 5Rs steps to Improve Healthcare Quality in the Hospital of CSMU,2019/9/17,11,2009年台灣麻醉品質與安全研討會,2019/9/17,12,2009年台灣麻醉品質與安全研討會,The Donabedians trilogy,2019/9/17,13,2009年台灣麻醉品質與安全研討會,Review and analysis,Item-by-item. ( Data will be presented by percentage for comparison ). SD, Mean, Mode,2019/9/17,14,2009年台灣麻醉品質與安全研討會,Retrain,Use PDCA cycle (plan, do, check retraining in the monthly meeting, discussion and presentation,2019/9/17,15,Reduce,Preventing the recurrence of similar cases or situations (especially for high incidence group) will reduce the number of unwanted event.,2019/9/17,16,2009年台灣麻醉品質與安全研討會,Proposed Safety Initiatives,1. Computer Physician Order Entry 2. Evidence-Based Hospital Referral 3. Physician Staffing in the ICU ( OR ),2019/9/17,17,