????????????????????? ?????????????? Clinical Tracer ?.?.?. ??????? ????????? ?.?.?.(?) ?????? ????????

1
???????????????????????????????????Clinical
Tracer?.?.?. ??????? ????????? ?.?.?.(?) ??????
????????
2
???????

• ???????????????????? ?????????????????
  ?????????????????????? ??????? ?????
  ??????????????? ??????????? ???????????
• ????????????? ?????????? ???????????
  ?????????????? ???????????????????????????????????
  ??
• ??????????????????????????????????????????????????
  ????????????? 

3
??????????

• ????????????????????? ?????????????
• ??????????????
• ???????????????
• ???????
• ??????????
• ????????????????????

4
??????????

• ????????????????????? ?????????????
  ?????????????????????????????????????
  ?????????????????????????????????
• ??????????????
• ???????????????
• ???????
• ??????????
• ????????????????????

5
??????????

• ????????????????????? ?????????????
• ?????????????? ???????????????????????????
• ???????????????
• ???????
• ??????????
• ????????????????????

6
??????????

• ????????????????????? ?????????????
• ??????????????
• ??????????????? ????????????????????????
  ??????????????????????????????????????????????????
  ????????????????????????????????????
• ???????
• ??????????
• ????????????????????

7
??????????

• ????????????????????? ?????????????
• ??????????????
• ???????????????
• ??????? ???????????????????? patient safety goal
  7 ????
• ??????????
• ????????????????????

8
??????????

• ????????????????????? ?????????????
• ??????????????
• ???????????????
• ???????
• ?????????? ???????????????????????????? 5 ???
  ?????? (?????????????, ???????????????????,
  ???????????, ??????????????? ???
  ????????????????????????????)
• ????????????????????

9
??????????

• ????????????????????? ?????????????
• ??????????????
• ???????????????
• ???????
• ??????????
• ???????????????????? ?????????????????????????????
  ??? ??? ????????? ??????? ??????????

10
?????????????????

• 1. ????????????????????
• 2. Patient safety goal ??????????????????????? 7
  ????
• 3. ?????????? ???????? ?? 5 ????????????
• 4. ???????????????? ??????????????????????

11
?????????????????????

• ???????????????????????????????????????????(gt80)
  2550 ??? 86.72
• ?????????????????????????????????(0 ) 25500
• ??????????? (0) 2550 ?? 4 ??? (?????????????1???)
  
• ?????????????????????? (100) 2550 ?? 4/5
  (??????NR1)
• ????????????????????????????????????????????(gt80)
  2550???85.23
• ??????????/???????????? (lt5) 2550 ??? 7.64
  2551 5.88

12
?????????????????

• 1. ????????????????????
• 2. Patient safety goal ??????????????????????? 7
  ????
• 3. ?????????? ???????? ?? 5 ????????????
• 4. ???????????????? ??????????????????????

13
Safety Goal

1. Patient identification
2. Operation safety
3. Medical safety
4. Health care associated infection
5. Morbidity Mortality
6. Delayed rescue
7. Communication failure

14
?????????????
Safety Goals
Entry confirm diagnosis Indication for surgery Patient identification
Assessment Medical Clearance Health Care Register/Insurance Medical safety
Planning ???????????? ????????? ???????????? ????????????? preop anesthesia Patient identification Operation safety
Care Delivery ICU/Intermediate ward medical consultation postoperative morbidity/mortality conference medical error Patient identification Delayed rescue Health care associated infection Morbidity Mortality Communication failure
Information Empowerment ?????????????????????????????????? ?.?. Communication failure
Discharge planning Continuity of Care Criteria Broschure Telephone consult Communication failure
15
?????????????????

• 1. ????????????????????
• 2. Patient safety goal ??????????????????????? 7
  ????
• 3. ?????????? ???????? ?? 5 ????????????
• 4. ???????????????? ??????????????????????

16
????????? 5 ???

• 1. OA knee 216
• 2. Fracture Hip 84
• 3. ACL injury 62
• 4. Degenerative spine 50
• 5. Fracture both bone of leg 19 (???????????3)

17
????????? Subspecialty

• 1. Trauma 619
• 2. HipKnee 417
• 3. Hand 393
• 4. Spine 261
• 5. Adult Reconstruction 115
• 6 SportMed 113

18
????????? (Major Operation)

• 1. TKA (Total Knee Arthroplasty) 196
• 2. Laminectomy 78
• 3. ACL Reconstruction 53
• 4. Hip Prosthesis 37
• 5. Open fx BB leg 15

19
?????????????????

• 1. ????????????????????
• 2. Patient safety goal ??????????????????????? 7
  ????
• 3. ?????????? ???????? ?? 5 ????????????
• 4. ???????????????? ??????????????????????
• ???????????????????????? ? ??????????????????
• ???????????????????????????????? ???? Hipknee,
  Sportmed, Spine
• ????????????????? ? ?????????? ??????????????
  ???? iliotibial friction syndrome

20
???????????????????????????????????
?????????????????????????????????????
21
????????????????????
22
?????????????
Safety Goals
Entry confirm diagnosis Indication for surgery Patient identification
Assessment Medical Clearance Health Care Register/Insurance Medical safety
Planning ???????????? ????????? ???????????? ????????????? preop anesthesia Patient identification Operation safety
Care Delivery ICU/Intermediate ward medical consultation postoperative morbidity/mortality conference medical error Patient identification Delayed rescue Health care associated infection Morbidity Mortality Communication failure
Information Empowerment ?????????????????????????????????? ?.?. Communication failure
Discharge planning Continuity of Care Criteria Broschure Telephone consult Communication failure
23
?????????????
Safety Goals
Entry confirm diagnosis Indication for surgery Patient identification
Assessment Medical Clearance Health Care Register/Insurance Medical safety
Planning ???????????? ????????? ???????????? ????????????? preop anesthesia Patient identification Operation safety
Care Delivery ICU/Intermediate ward medical consultation postoperative morbidity/mortality conference medical error Patient identification Delayed rescue Health care associated infection Morbidity Mortality Communication failure
Information Empowerment ?????????????????????????????????? ?.?. Communication failure
Discharge planning Continuity of Care Criteria Broschure Telephone consult Communication failure
24
OA knee - OPD

• ??? ??? ?? ????????????
• ??????????
• ???????????
• ??????????

25
OA knee - Diagnosis

• ???????? ????????
• ?????????????
• ???
• ???
• ??????????????
• ??????????

26
OA Knee -Treatment

• ???????????? ???????????????????????
• ????????? ??????????
• ??????????? ????? ????????
• Knee Brace ??????????????
• Cane ???????

27
Medication

• Pain Killer ???? paracetamol
  
• NSAIDs / cox2inh ???????????????
• DMOD(Disease Modifying Drug for Osteoarthritis)
• -Glucosamine SO4 1500??.,???????????? 2
  ?????

28
?????????????????

• Arthroscopic Debridement/Abrasion
• Corrective Osteotomy (HTOHigh tibial Osteotomy)
• Arthroplasty (TKA-Total knee Arthroplasty)

29
????????????????????????????????

• Severe Arthritis
• Pain is significant and disabling
• Dysfunction significant reduction in the
  patient's quality of life
• Night pain is particularly distressing
• Failure of conservative treatment

30
?????????????
Safety Goals
Entry confirm diagnosis Indication for surgery Patient identification
Assessment Medical Clearance Health Care Register/Insurance Medical safety
Planning ???????????? ????????? ???????????? ????????????? preop anesthesia Patient identification Operation safety
Care Delivery ICU/Intermediate ward medical consultation postoperative morbidity/mortality conference medical error Patient identification Delayed rescue Health care associated infection Morbidity Mortality Communication failure
Information Empowerment ?????????????????????????????????? ?.?. Communication failure
Discharge planning Continuity of Care Criteria Broschure Telephone consult Communication failure
31
Medical Clearance History

• Old age
• Medical problem HT DM MI
• ??????? 65,000 ??? ???????????? 30,000

32
Medical clearance ????????
33
Medical clearance
34
Medical clearance pre-op
35
Medical clearance ????
36
Medical clearance plan
37
Medical clearance pre-op
38
Medical clearance pre-op
39
Medical clearance pre-op
40
Medical clearance gt pre-op
41
?????????????

• Medical clearance ?????????? ??? pre-op
  ???????????????????????????????????????
• ?????????????????

42
complication

• polyethylene wear
• instability
• aseptic Loosening
• extensor mechanism dysfunction
• unexplained pain
• infection.

43
Infection

• Rate 1-2
• Our rate 0.53

44
????????????????

• ????????????????????????????
• Revision ???????????

45
???????????

• ?????????????????
• ?????????????????
• ??????????????????
• ????????

46
Doctor at OPD

• ???? ??????????? Xray (5 ??????????)
• ?????????????? ?????
• ?????????????? ????????? ???????????
• ?????????????? ????????????????? 2
  ??????????????????????????????
• ???????? lab ???? pre-op evaluation
• ??????????????????? ????????? Med ???????????OPD
  ?????????????
• ??????????????? medical finance clear
• ???????????????????????????????? 1 ???
  ????????????????? ?????????????

47
????????
48
???????? (????)
49
????? ??? ?????
50
OPD Nurse

• ???????-????????? ??????????????????? ???? ASA
  NSAIDs ????????? ?????????????????????? 2549-96,
  2550-98
• ??????? ???????????????????????? ???? ????? UTI
• ??????? ????? ???????????????????
• ?????????????? ????????????????????
• ??????????????????????????????????????????????

51
?????????????
Safety Goals
Entry confirm diagnosis Indication for surgery Patient identification
Assessment Medical Clearance Health Care Register/Insurance Medical safety
Planning ???????????? ????????? ???????????? ????????????? preop anesthesia Patient identification Operation safety
Care Delivery ICU/Intermediate ward medical consultation postoperative morbidity/mortality conference medical error Patient identification Delayed rescue Health care associated infection Morbidity Mortality Communication failure
Information Empowerment ?????????????????????????????????? ?.?. Communication failure
Discharge planning Continuity of Care Criteria Broschure Telephone consult Communication failure
52
Ward pre-op

• ?????????????????????????

53
????????????
54
??????????????????????????????????????????????????
?????
55
Identification

• ????????????? gt?????????????
• gtMark site

56
Anasth visit

• Recheck

57
OR Nurse visit
58
Operation

• ????????????????
• gtRe Identify
• -staff 8.30
• -resident 9.00

59
?????????????????????????????????

• One way traffic
• Surgical Drape
• Aseptic restriction

60
?????????????
Safety Goals
Entry confirm diagnosis Indication for surgery Patient identification
Assessment Medical Clearance Health Care Register/Insurance Medical safety
Planning ???????????? ????????? ???????????? ????????????? preop anesthesia Patient identification Operation safety
Care Delivery ICU/Intermediate ward medical consultation postoperative morbidity/mortality conference medical error Patient identification Delayed rescue Health care associated infection Morbidity Mortality Communication failure
Information Empowerment ?????????????????????????????????? ?.?. Communication failure
Discharge planning Continuity of Care Criteria Broschure Telephone consult Communication failure
61
Post op

• Pain gt Pain Management
• Blood loss gt I/O Imbalance

62
Epidural Morphine Complication?????????

• ?????????????????(??????) ???????????????? 5 ???
• ????????????????????? 3 ???
• ????????????????? ???????????? routine
  ??????????????????????????????????????????????????
  ??????????????

63
Epidural Morphine Complication ????????

• ??????????????? ??????? ????????????18 ???????
  ?????????????????????? pain score, sedation
  score, RR, vital sign ????? o2 sat ????
• ??????????????????????????
• ??????? ?????????????????
• ????????? ?????? ?????????

64
Anesth Order
65
Epidural Morphine Complication???????

• ?????????????????????????????
• ??????? ??? (??????????????????????) ??????????
• ????????? ??????????? ?????????????????????
  ??????????????????????????????
• 2551 ?? 1 ?????????????? morphine intra-Articular
  
• gt ??????????????? ?? Morphine ???????

66
Delayed Rescue gt CPR

• Rapid response team
• ??????????? CPR ???????
• ???????
• CPR lt4 min (90) 3/7 gt 4/5
• ????????????(??????????) (0) 4/7 gt 0/5
• ????????????? (0) 4/7 gt
  1/5(??????)
• 2549 2550

67
Conference

• Morning report
• Topic review
• Grandround
• Journal club
• Morbid
• Mortality
• Interdepartment
• InterHospital
• Pre-op
• Post-op

68
Morbid Mortality conference

• -IV fluid 60ml/hr , 150ml/hr
• -hypovolumic / cardiogenic ?
• -Iv load x3times
• -Staff on duty on Monday
• Mortality RCA ???????????? ???? ??? lab CXR EKG

69
Post-op Order
70
???????? 3 ?????
71
?????????
72
(No Transcript)
73
????????????

• ?????????????? 2/9
• ??????????????????? 1/9
• ?????????????????????? 1/9
• ???????????????????? 5/9
• ?????????????????? 0

74
????? ???????
????? ????????????? ???????????????????? ???????????????????????? ??????????????? ???????????????????????? ?????????? ??????????????????????? ???? I/O q 1 hr ?????? order ??????????
75
????? ???????

• ?????????????
• ?????????? ?????????? ???????????? classic
• ?????????????? ?????????
• ?????? ?????????? ???????????????? order

76
Post-op order2
77
???????? 1 ?????
78
Post-op Doctors Order Sheet for patient at risk

• 1)gt60y ?????????????????????????
• 2)Prosthesis ?????????????????????????????????????
  ???
• 3) Spine ??????????????????????????????????????
• 4)Pelvis ???????????????????????????????????????
• 5)Hip ????????????????????????????????????
• 6)Multiple Injury ???????????????????????????????
• 7)?????????? ??????????????

79
Post-op order ????????
80
Critical order
81
?????????????
Safety Goals
Entry confirm diagnosis Indication for surgery Patient identification
Assessment Medical Clearance Health Care Register/Insurance Medical safety
Planning ???????????? ????????? ???????????? ????????????? preop anesthesia Patient identification Operation safety
Care Delivery ICU/Intermediate ward medical consultation postoperative morbidity/mortality conference medical error Patient identification Delayed rescue Health care associated infection Morbidity Mortality Communication failure
Information Empowerment ?????????????????????????????????? ?.?. Communication failure
Discharge planning Continuity of Care Criteria Broschure Telephone consult Communication failure
82
????????????
83
????????????????????
84
?????????????????????????
85
???????????????????
86
Innovation???????????????????

• CPM
• (Continuous passive motion)
• -???????
• -????????
• -????????????

87
(No Transcript)
88
Ward CQI

• ????????????????????????????? Morphine ???
  Epiural Catheter
• ?????????????????????????????????????????
• ??????????????????????????????????????????????????
  ?????????????????????????????????
• ????????????????????

89
??????????????

• ??????????????????????? ??????????????????????
  ??????????????????????????? ??????????????????????
  ?????????? 100??????????? Condition ???????????
  
• ????????????????????????????? 2 ??????????
• ????????? 90???? ????? 4 ?????????????
• ??????????????????????? ?????????? ?????????????
  ?????????????? 13 ???
• ????????????????????????????? ??????????????
  ???? Dypnea ???????????? Morphine ??? Epidural
  Catheter 100 ??? ?????????????????????????
• ??????????????????????????????

90
??????????????????????

• ??????????????????????????????????????????????????
  
• ????????????????????????????(lt2) 0.44gt0.53
• Complication of Morphine(0) 0.96gt1/279(0.36)
• Deep vein thrombosis(lt2) 2/208gt0/279
• Myocardial infarction(0) 1/208gt0/279

91

Safety Goal Problem Activity ?????????
Patient identification ????????????????? ReIdentification ????? 0
Operation safety ??????????????????????????? Mark side ??????? 0
Medical safety Epidural Morphine cx, DVT, MI medical clearance, Anesth Order, post-op order Morphine cx 1 (intraMo), DVT0, MI 0
Health care associated infection ???????????????????? oneway OR,Surgical Drape, Aseptic restrict ???????????????????? (1) 0.53
Morbidity Mortality Mortality Conference, RCA Mortality 0 (Hip1)
Delayed rescue ?????????????????? 4/5 post-op order, CPR ??????????????????0
Communication failure ???????????????? Broschure ????????????, CAI ????????? 100
92
?????? ???????? HA

• ????????????? ??????????????
• ???????????? ????????
• ??????????

93
Thank you