Investigation of unplanned-extubation of endotracheal tube by health-care matrix and root cause analysis

• Main Authors: Wen-Kai Tsai, 蔡文凱
• Other Authors: Chuen-Ming Chih
• Format: Others
• Language: zh-TW
• Published: 2010
• Online Access: http://ndltd.ncl.edu.tw/handle/56351045545704651896

碩士 === 雲林科技大學 === 健康產業管理研究所碩士班 === 98 === A procedure is based on the concept of medical care with "patient-centered" and "patient safety". In recent years, tube safety is one of the nine goals of patient safety. Literatures pointed out that the tube events are high risk and high frequency of accidents in intensive care unit. According to Taiwan''s patient safety reporting system (TPRs), tube-related incidents accounted for 10-11% and they can cause major complications and death. This research applied root cause analysis (RCA) and "Health Care Matrix": We find that the most frequent occurrence of unplanned extubation, happened at the day shift, junior nurse in rank, and patients of internal medicine. The situation of patients of self-extubation mainly are awake, without usage of sedative agents and non-restriction status. The re-intubation rate is 22.7%. Therefore the basic problems are: 1. Awake patients are uncooperative and attempt to extubation. 2. Insufficient pre-employment training of new stuff leading to inadequate knowledge. 3. The lack of integrity of the assessment of medical treatment and sedatives treatment timely. 4. The lack of medical team to discuss the extubation time. Further, using healthcare matrix to find out feasible improvement plan: initially, the clinical team reviewed the process of patient care to identify whether each of the six quality aims had been reached, and then qualified by six competencies: medical knowledge and skills, interpersonal and communication skills, professionalism, system-based practice and practice-based learning and improvement. The results provide the introspection and the improvement method in safe, timely and effective. These findings may provide the guide for medical team to assess the self-extubation patients, and suitable measure for high risk group such as awake patients without sedatives and physical restriction. Because the appropriate prevention of unplanned-extubation for reducing the incidence and injury, thereby ensuring patient safety, to improve the quality of care and reduce medical resource utilization win-win situation.