中華民國 113 年 11 月 24 日

 
 
病安目標
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JCAHO目標
【 資料來源：醫策會 】
 
2006年JCAHO病人安全目標
　　美國評鑑機構聯合會(Joint Commission on Accreditation of Healthcare Organization; JCAHO)為促進病人安全方面有具體改進的作法而於每年7月提出年度國家病人安全目標。其形成主要是由JCAHO 病人安全通訊、警訊事件警示等機制，非正式的建議而來。這些目標強調出醫療照護中有問題的區塊，藉由科學證據和專家提出解決問題的方法。病人安全目標的重點放在系統範圍內可解決的方向，JCAHO 也提供如何有效的達到每個目標要求的指引。 2006 年其目標及要點如下：

Goal 1：Improve the accuracy of patient identification.
（目標一： 提昇病人辨識的正確性）
標題符號 Use at least two patient identifiers (neither to be the patient's room number) whenever administering medications or blood products; taking blood samples and other specimens for clinical testing, or providing any other treatments or procedures.
  無論是給藥、輸血、採血、特殊的臨床檢查、及其他治療或執行照護時，應使用至少兩種辨識病人身份的方法（不含病人的房號或床號）
標題符號 Prior to the start of any invasive procedure, conduct a final verification process to confirm the correct resident, procedure, site, and availability of appropriate documents. This verification process uses active—not passive—communication techniques.
 

在執行任何侵入性的處置之前，要對病人、處置、部位做最後的確認，並做成適當的書面記錄。這些確認的程序需透過主動溝通的技巧達成。

Goal 2：Improve the effectiveness of communication among caregivers.
（目標二：提昇醫護人員之間溝通的有效性）
標題符號 For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the order or test result "read-back" the complete order or test result.
  執行口頭或電話醫囑或以電話報告重要的檢查結果，應以"重複複誦"的方式以確保訊息接受者收到正確的醫囑或檢查結果的報告。
標題符號 Standardize a list of abbreviations, acronyms and symbols that are not to be used throughout the organization.
  將醫院內不得使用之易犯錯的縮寫、簡稱及符號訂出統一之標準，並詳列之。
標題符號 Measure, assess and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values.
  量測、評估並適時地改善檢查/檢驗報告完成以及主要負責照護人員接獲報告結果之即時性。
標題符號 All values defined as critical by the laboratory are reported directly to a responsible licensed caregiver within time frames established by the laboratory (defined in cooperation with nursing and medical staff). When the patient’s responsible licensed caregiver is not available within the time frames, there is a mechanism to report the critical information to an alternative responsible caregiver.
 

當出現檢驗危險值時，應在規定的時限內通報主要負責照顧人員，若在時限內無法與主要負責照顧人員聯繫上，應有將此訊息提供給其代理人的機制。
標題符號 Implement a standardized approach to "hand off" communications, including an opportunity to ask and respond to questions.
  執行標準化之"交班溝通"事項，且交班時應要有提問與回應問題的機制。

Goal 3：Improve the safety of using medications.
（目標三：改善用藥的安全性）
標題符號 Retired in 2006. [Remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, sodium chloride >0.9%) from patient care units.]
 

2006 年已取消。[單位內不存放濃縮電解液（包含但不限於氯化鉀、磷酸鉀及濃度大於0.9 的氯化鈉等。）]
標題符號 Standardize and limit the number of drug concentrations available in the organization.
  限定醫院內同一藥品不同濃度之品項數並訂定規範。
標題符號 Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used in the organization, and take action to prevent errors involving the interchange of these drugs.
  每年至少檢視及確認一次醫院內使用藥品中，外觀相似或發音相似的藥品清單，並需採取因藥品外觀相似或發音相似導致混淆錯誤的防範措施。
標題符號 Label all medications, medication containers (e.g., syringes, medicine cups, basins), or other.solutions on and off the sterile field in perioperative and other procedural settings.
 

對於會重複接觸無菌區的藥品、藥物容器（如注射針劑、藥杯、彎盆）或其他的溶液應標示清楚。

Goal 4：Eliminate wrong-site, wrong-patient, wrong-procedure surgery.
（目標四：消除手術部位錯誤、病人錯誤、術式錯誤）
標題符號

Create and use a preoperative verification process, such as a checklist, to confirm that appropriate documents (e.g., medical records, imaging studies) are available.
 

建立並進行手術前確認流程（可使用查核表等工具），以確保病歷紀錄、影像資訊等文件資料準備齊全。
標題符號 Implement a process to mark the surgical site and involve the patient in the marking process.
  建立手術部位標記的程序，且需包含讓病人參與共同確認的流程。

Goal 5：Retired in 2006. [Improve the safety of using infusion pumps.]
（目標五：2006 年已取消[改善輸液幫浦的使用安全]）
標題符號

Retired in 2006. [Ensure free-flow protection on all general-use and PCA (patient controlled analgesia) intravenous infusion pumps used in the organization.]
 

2006 年已取消[確保醫院內一般使用及病患控制止痛法(Patient Controlled Analgesia, PCA)專用之靜脈輸液幫浦具流量失控之防護措施。]

Goal 6：Improve the effectiveness of clinical alarm systems.
（目標六：提升臨床警示系統的有效性）
標題符號 Implement regular preventive maintenance and testing of alarm systems.
  執行警示系統的日常預防保養與測試。
標題符號

Assure that alarms are activated with appropriate settings and are sufficiently audible with respect to distances and competing noise within the unit.
 

確定警示系統的設定與運作功能正常，其警示聲響可以克服距離與單位內的噪音等因素，可被清楚的聽到。

Goal 7：Reduce the risk of health care-associated infections.
（目標七：減少健康照護所致感染之風險）
標題符號 Comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines.
  遵從疾病管制局所訂定的手部衛生指引。
標題符號 Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-associated infection.
  對於所有與感染相關的非預期性死亡或造成永久性身體功能喪失的個案，皆應列入警訊事件妥善管理。

Goal 8 : Accurately and completely reconcile medications across the continuum of care.
（目標八：確保病人持續性照護之用藥正確性及完整性）
標題符號 Implement a process for obtaining and documenting a complete list of the patient's current medications upon the patient's admission to the organization and with the involvement of the patient. This process includes a comparison of the medications the organization provides to those on the list.
 

發展一流程以便掌握病人先前就醫時所接受的藥物治療清單完整紀錄，並使該紀錄能與病人來院的就診紀錄一起保存，紀錄中應包括醫院提供的藥物對照表。
標題符號 A complete list of the patient's medications is communicated to the next provider of service when it refers or transfers a patient to another setting, service, practitioner or level of care within or outside the organization.
  當病人轉單位或轉院時，完整的病人藥物治療明細應能正確的被傳遞至下一個照護者手中，以進行進一步相關醫療服務。

Goal 9: Reduce the risk of patient harm resulting from falls.
（目標九：減少病人因跌倒造成傷害的風險）
標題符號 Implement a fall reduction program and evaluate the effectiveness of the program. Replacement for 9A (Assess and periodically reassess each patient's risk for falling, including the potential risk associated with the patient's medication regimen, and take action to address any identified risks.
 

建立降低病患跌倒的計畫並評估其有效性。取代9A （評估且視需要定期地再確認每一個病人跌倒可能的風險，包含病人因用藥而發生的危險並針對確認的風險採取預防或改善措施。)

Goal 10: Reduce the risk of influenza and pneumococcal disease in older adults.
（目標十：降低老年人罹患流行性感冒及肺炎的風險）
標題符號 Develop and implement a protocol for administration and documentation of the flu vaccine.
 

建立流行性感冒疫苗的管理辦法。
標題符號 Develop and implement a protocol for administration and documentation of the pneumococcus vaccine.
  建立肺炎疫苗的管理辦法。
標題符號 Develop and implement a protocol to identify new cases of influenza and to manage an outbreak.
  建立及實施流行性感冒新病例的辨識辦法，並設置避免爆發流行之規範。

Goal 11: Reduce the risk of surgical fires.
（目標十一：降低手術失火的風險）
標題符號 Educate staff, including operating licensed independent practitioners and anesthesia providers, on how to control heat sources and manage fuels, and establish guidelines to minimize oxygen concentration under drapes.
 

教育全體工作人員，含獨立開業醫及麻醉藥品提供者如何控制熱源與燃料，並建立作業指引，避免高濃度之氧氣集中在氧氣罩下方。

Goal 12: Implement applicable National Patient Safety Goals and Requirementsat the component and practitioner site levels.
（目標十二：基層醫療院所層級需要執行適當的病人安全目標與要求）
標題符號

Inform and encourage components and practitioner sites to implement applicable National Patient Safety Goals and Requirements.

 

告知並鼓勵基層醫療院所層級設定適當的病人安全目標與要求。

Goal 13: Encourage the active involvement of residents and their families in theresident’s care as a resident safety strategy.
（目標十三：病人安全策略應含鼓勵病人及其家屬主動參與病患照護）
標題符號

Define and communicate the means for residents and their families to report concerns about safety and encourage them to do so.
 

鼓勵住民及其家屬與照護人員溝通他們所關心的安全議題。

Goal 14: Prevent health care-associated pressure ulcers (decubitus ulcers).
（目標十四：避免因健康照護造成的壓瘡）
標題符號 Assess and periodically reassess each resident's risk for developing a pressure ulcer (decubitus ulcer) and take action to address any identified risks.
 

定期的評估每個病人產生壓瘡的風險，並對具有風險之病人進行處置。
 
     
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