臺灣博碩士論文加值系統

雖然搭乘飛機非常安全，發生意外的機會比搭乘汽車還少，歷年來還是發生幾件嚴重的空難讓航空業者得到慘痛的教訓。航空業很早就分析出人為因素造成的空難佔空難總數的76%，其中大多數的錯誤來自不良的溝通與合作，而非個人因素。所以航空界在上個世紀八十年代就推行機組資源管理(Crew Resource Management)，以減少因為溝通問題所導致之不幸。醫療業與航空業一樣，客戶安全是主要目標，醫師與機師具有相似的專業特質，兩者都是從事高風險工作，經常要處理生死攸關的事務，研究更顯示大多數可預防的醫療不良事件都是因為人為錯誤所致，而大部份的人為錯誤又都是因為醫療團隊不好的溝通及合作不佳導致，所以醫療界向航空界取經，也注意到團隊資源管理教育訓練課程。
在醫院各部門中，急診部門由於其特殊的工作性質與醫療環境，醫療錯誤發生的風險比其他醫療單位更高，急診醫療錯誤的增加，也可能和組織文化、個人信念、態度、價值有關。我們認為若能在急診部門有效實施團隊資源管理 (TRM)，將能促進團隊效率，減少臨床錯誤，進而可以增進病人安全，減少醫療糾紛，所以本文所研究這家地區教學醫院在2009年12月導入TRM課程，而以急診部門為優先實行單位，急診部門共有四位主治醫師及三十三位護理人員加入此訓練。首先參與兩天課程，老師除了講授組織領導統御技巧、團隊互助、溝通及克服團隊合作障礙之種種策略與工具，也利用各種實際案例作情境練習。上課後，學員利用上課學得之種種策略與工具，運用在日常工作裡，促進護理人員與醫師間之溝通、瞭解彼此的想法、釐清疑問、互相提醒以達到關懷同儕(醫師vs.護理人員)、增進團隊工作氣氛、舒緩工作壓力(尤其是新進人員)，進而提升病人安全，減少病安異常案件數。
我們採用問卷調查法，以醫策會2008年設計之醫院病人安全態度量表（Safety Attitudes Questionnaire,SAQ）為藍本。問卷設計包括基本資料(性別、年齡、職務別、工作年資)及六大構面(團隊合作、單位安全的風氣、對工作的滿意、對管理的感受、工作狀況、對壓力的認知共三十題)。探討個案醫院於導入TRM前後，急診室醫護人員對病人安全文化認知程度及對團隊整體的認同度的差異。結果發現，整體來看六個構面的後測分數皆高於前測，在前、後測問卷中「團隊合作構面」「單位安全風氣構面」「對管理感受構面」「對壓力的認知構面」皆達統計上顯著意義 (p<0.05)。其中對於壓力認知分數增加幅度最高，表示醫療人員在高風險的環境中工作時，TRM訓練能有效的提升壓力認知，工作人員可保有一定的警覺性，對提升病人安全有正面意義。而在六個構面當中，「對工作的滿意構面」及「工作狀況構面」兩項差異不大，顯示出急診單位同仁認為對切身的工作場所及同仁相處仍有改善之處，在進一步分析後，「在單位工作就像一個大家庭中的一份子」及「單位的臨床人力配置足以處理病人工作量」兩子項是同仁最不滿意的，值得單位主管及醫院高層重視，應該著手增進同仁向心力與儘速補足欠缺人力。急診部門醫護同仁一致高度肯定TRM訓練能有效增進團隊組織相關知識及效能，部門間的溝通與交班更精緻，組員間也能一起作正確的決定。我們也強烈建議急診部門外醫院之一般部門也應該接受TRM訓練與推廣，讓各部門溝通與合作更有效率，病人安全更有保障。
自2007年起美國醫院評鑑機構建議所有醫院必需進行年度病人安全文化自我評量，本研究運用 SAQ 調查病人安全文化，除了可以瞭解急診醫護人員病人安全態度之外，未來更可搭配品質管理手法、醫療資訊系統的介入，縱向追蹤急診醫護人員安全態度與病人安全之間的聯繫性，改善急診安全文化。在國際及國內已發表有關TRM之論文均以大型醫院為對象，鮮少以地區醫院為研究對象，我們研究證實在地區教學醫院導入TRM課程後確實可以有效的提升急診室醫護人員對病人安全文化的認知，期能作為醫療同業的參考。

Air travel is and has been a very safe method of transportation and has had fewer accidents overall than by automobile. However, over the years occurrences of serious crashes have made a few airlines aware of some important issues that need to be addressed. An analysis of the aviation industry showed that of 76% of crashes caused by human error, poor communication was the main factor in the cause of the crashes.
Therefore during the eighties the aviation industry implemented a Crew Resource Management plan to train airline staff in an effort to reduce communication problems that have been the cause of previous accidents and to prevent future ones from happening. Customer safety in the aviation industry is paramount and not different in the medical industry. Doctors and Pilots both are often placed in high stress situations in their perspective occupations requiring them to make on the spot decisions at times dealing with life or death. Research in the medical industry has also shown that many unfortunate incidents in this field have also occurred due to poor communication and cooperation amongst the medical team. In an effort to rectify this, the medical industry has learned from the aviation industry and taken note of the Team Resource Management training courses implemented by them.
Due to the fast paced and specialized nature of the Emergency Department compared to other departments in a hospital there is a greater risk of medical errors. There are also a variety of factors that may contribute to cause errors including the organization of the department, personal beliefs, attitudes and values of the medical staff. If the (TRM) can be effectively implemented in the Emergency Department it is believed that staff efficiency will increase and overall clinical errors will be reduced. From this reduction patient safety will have raised and lower the amount of medical disputes. To follow through with this hypothesis In December 2009 this hospital implemented a TRM course for the Emergency Department where a total of four physicians and thirty-three nurses took part in the Team Resource Management training program. For the first two days of classes the instructor gave lectures on organizational/leadership skills, team solidarity, communication and teamwork. This helped to build a knowledge base to help overcome any obstacles the class would come upon in the future. The instructor also taught different strategies and tool use with the aid of actual cases for situational exercises. Upon completion of the TRM training course students used what they had learned in their daily tasks at work. They were to communicate well with each other making sure to clarify ideas and questions as well as reminding each other to care about one another (physicians vs. nurses). This was all to promote a team environment where everybody had to work together to achieve common goals and was noted especially for newer staff. These efforts would enhance overall patient safety and reduce the amount of cases of subpar patient safety.
We created a questionnaire based on the 2008 Medical Design III Hospital Patient Safety Attitude Scale (Safety Attitudes Questionnaire, SAQ). The questionnaire design included basic information of staff members (gender, age, occupation, and years of experience) as well as six other categories (teamwork, unit safety, job satisfaction, management experience, working conditions, and awareness of work pressure) for a total of thirty questions. Some of the questions asked about emergency room staff awareness of patient safety as well as degree of recognition of the team before and after the implementation of the TRM program. The overall results of the questionnaire showed the six categories post-test scores were higher than pre-test scores. The initial pre-test and post-test questionnaire for teamwork, unit safety, job satisfaction, management experience, and awareness of work conditions, are of statistical significance (p <0.05). Awareness scores for work pressure had the highest rate of increase showing that staff working in a high-stress work environment can effectively be taught to be more alert and aware of their surroundings using the TRM program. This has a substantial positive effect in improving patient safety overall. Among the six categories, the score difference between job satisfaction and work conditions were minimal and shows there is room for improvement Upon further research it was discovered that staff members felt like they were working within their own family but felt there were issues with being properly staffed for the amount of patients admitted. Management teams and hospitals should be aware of these factors and rectify these issues in order to raise morale and increase solidarity within departmental units. Staff in the emergency department all strongly agreed that the TRM program would improve not only knowledge and functionality related to teamwork, but also communication between each department. It would also enhance the quality of duty handed over to the next shift and staff members would be able to make correct decisions together. It is highly recommended that each department of a hospital receive the TRM program other than the Emergency Department. This would allow all departments of a hospital to work more effectively as an entire team due to stronger communication and cooperation skills thereby enabling a higher quality of patient safety.
Following the year 2007 all US hospitals have been instructed by the U.S. Hospital Accreditation Agency to conduct annual patient safety self assessments. The study investigates the use of SAQ patient safety as well as understanding the attitudes of emergency staff to patient safety. This information would also be used for the quality of management practices in the future as well as any other medical information systems. All data collected would go towards tracking the vertical attitude and links between patient safety and improved emergency safety knowledge. In local hospitals it is rare to find the TRM program despite that there have been essays written about it domestically and internationally directed for use in larger facilities. Throughout this research it has been proven that applying the TRM courses at local teaching hospitals can ensure efficiency in upcoming emergency staff. They would be taught due diligence in patient safety and would serve as a marker for parallel trades to follow.

書名頁……………………………………………………………………i
論文口試委員審定書 …………………………………………………ii
授權書 …………………………………………………………………iii
中文提要 ………………………………………………………………iv
英文提要 ………………………………………………………………vi
誌謝 ……………………………………………………………………ix
目錄 ……………………………………………………………………x
表目錄 …………………………………………………………………xi
圖目錄 …………………………………………………………………xii
第一章 緒論 ………………………………………………….……1
第一節 研究背景與動機 …………………………………………1
第二節 研究目的 …………………………………………………3
第三節 研究流程……………………………………………………5
第二章 文獻探討 ……………………………………….…………6
第一節 病人安全文化的定義、發展 …………………………….…6
第二節 團隊資源管理（TRM）的定義及理論基礎 ……………….9
第三節 TeamSTEPPS的定義與推行 …………………………………13
第四節 TRM與病人安全文化相關性研究及衡量構面探討 …………17
第三章 研究方法 …………………………………………………20
第一節 研究架構 ……………………………………………….…21
第二節 研究假設 ……………………………………………….…23
第三節 量表設計及衡量方式 ………………………………….…24
第四節 抽樣設計 …………………………………………….……24
第五節 資料處理與統計方法 ………………………………….…25
第四章 研究結果 ……………………………………………..…27
第一節 病人安全文化量表六個構面分析 …………………..…27
第二節 信度分析……………………………………………..……32
第三節 成對樣本T檢定…………………………………….………35
第五章 結論與建議 ………………………………………………37
第一節 研究結論 …………………………………………….……37
第二節 研究限制 ……………………………………………….…41
第三節 後續研究建議………………………………………….… 41
參考文獻 ………………………………………………………………44
中文參考文獻 …………………………………………………………44
英文參考文獻 …………………………………………………………46
附錄一：病人安全文化調查問卷 ……………………………………50

參 考 文 獻
中文參考文獻
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