HEALS鱼骨图1

这是一篇关于的思维导图，主要内容包括：Process，People，Management，Environment，Method，Equipment。

• Equipment
  • Thermometer
  • Stethoscope
    • • Noise
  • RDR Chart
  • Digital BP Machines
    • • Less Accurate
      • Cuff Size
      • Position
  • Manual BP Machines
  • Forehead SpO2 Sensor
  • Pulse Oximetry
    • • Inaccurate When Perfusion Decreased
      • Missing the Strength/Rhythems of Pulse
  • Timer
• Method
  • Measurement
    • • Not Manual
      • Missing Elements
      • Inaccurate Machine Readings
  • Interpretation
    • • Missing Trends
      • Not Using Early Warning Scores
      • Only Focus Zones in RDR Chart
      • Lack Clinical Judgement
• Environment
  • Inpatient Units
    • • No Further Plan After Stabilised
      • Late When Found
      • Interrupted
      • Frequency Not updated
      • Delaid Routine Check
  • During MET Call
    • • Delayed Monitoring
      • Readings far beyond Expected Range
      • Missing Patient Pattern
• Management
  • Lack Personalised Plan
    • • Not Risk Screening
      • Not Updated Adjustment
      • Missing Patient Pattern
  • Lack Training and Education
  • Less Detailed Protocols
    • • Unsure
      • More Time to Plan
  • Inadequate Communication
  • Insufficient Coordination
    • • Unclear Responsibilities
      • Less Organised
  • Inadequate Communication
  • Lack of Evaluation
    • • Indirect Outcomes
      • Cut the Corner
• People
  • Patient
    • • Not Compliant
        • • Not Knowing the Importance
          • Lack Trust
      • Individual Factors
        • • Varied Baseline
          • Potential Risk
          • Changes During the Day
  • Nurses
    • • Lack Interpretation
        • • Lack Education
          • Too Task-Focused
          • Relying on Sunrise Systems
          • Lack of Awareness
      • Lack Time Management
        • • Work Overload
          • Lack Clear Guidance
          • Lack Prioritisation
      • Lack of Support
      • Ineffective Communication
  • Doctor
    • • Not First Hand
      • Lack of Continuity
      • Delayed Communication
        • • Lack of Information
          • Nurses Not Escalate
• Process
  • Frequency
    • • Lack Guidelines
      • Lack Evaluation
      • Lack Risk Screening
  • Lack Team-Work
  • Lack Interactions
  • Inaccurate Readings
    • • Not Choosing Right Method
      • Lack Interpretation
  • Lack Communication
  • Delayed Escalations
    • • Wrong Interpretation
      • Complicated Process
      • Fear of False Alarms
• Delay in responding to patient deterioration
• 患者/家属
• 环境
• 管理
• 护理人员