運用醫療失效模式與效應分析於呼吸管路安全之改善

Use of Healthcare Failure Mode and Effects Analysis in Improving the Safety of Respiratory Tube

劉彩娥(Tsai-Er Liu)

指導教授 ： 應立志

中臺科技大學/管理學院/醫護管理研究所/碩士(2010年)

https://doi.org/10.6822/CTUST.2010.00001

摘要

近十年來世界各國爆發醫療不良事件層出不窮，民眾不再迷失醫療是無錯誤的健康服務。尤其在急重症醫療照護過程中，病人若發生人工呼吸道意外，重則造成病人立即死亡、腦部永久缺氧受損，輕則延長住院時間或產生新的併發症。故2008年衛生署將「管路安全」列入病人安全工作目標之ㄧ，足見呼吸管路安全維護之重要性。醫療失效模式及效應分析(HFMEA)為預應式風險管理方法，美國健康照護組織評鑑聯合委員會（JCAHO）與台灣新制醫院評鑑皆將此方法列為建議措施。本研究即運用HFMEA改善呼吸管路照護系統，找出危害管路安全之發生原因，並提出改善方案，以降低呼吸管路意外事件發生率，保障病人安全。
研究對象為中區某區域教學醫院呼吸照護單位，共計五個單位。研究小組以呼吸管路照護流程為分析主軸，將照護系統區分為呼吸管路置入前評估、呼吸管路置入中照護、呼吸管路置入後照護及呼吸管路脫離前照護等四個次流程，並結合呼吸管路異常事件通報分析，發掘可能影響呼吸管路照護安全之因素。
研究結果發現呼吸管路照護流程共計存在67項潛在失效模式及133個潛在失效因子，具高風險係數及決策樹分析需優先介入改善之潛在失效模式有26項，而潛在失效因子有35項。包含：病人清醒無法配合、未評估鎮靜劑使用需求、鎮靜劑使用劑量評估或使用錯誤、約束方式錯誤、病人身體被約束身心不適、照護人員未將管路擺放於正確位置、潮濕器忘記加水或加水過量、護理人員不會排除異常警報狀況、醫護病間未建立有效溝通、未建立脫離呼吸器訓練標準流程、未定期評估脫離呼吸器設定模式之適當性…等需改善之潛在失效模式。並依「病人生理及行為因素」、「工作流程設計、狀態因素」、「醫護人員個人因素」、「人員溝通因素」等四項予以分類，分別提出改善方案。
本研究追蹤其改善成效，在呼吸管路非計畫性滑脫率及呼吸器相關感染發生率進行改善前後t檢定，呼吸管路非計畫性滑脫率p=0.028；呼吸器相關肺炎發生率p=0.034，皆達統計上顯著差異。此研究結果可提供醫療機構作為呼吸管路安全維護之參考。

關鍵字

醫療失效模式與效應分析 ； 呼吸管路安全

並列摘要

Medical adverse events happened incessantly around the world in recent ten years. People no longer believe medical service is unmistakable. Especially, in the process of emergency and intensive care, artificial airway accident will cause immediate patient damage from immediate death, permanent hypoxic brain damage to prolonged hospital stay and new complications. Tube security was one of patient safety goal of department of healthy in 2008. It showed the importance of respiratory airway maintenance. Healthcare Failure Mode and Effects Analysis (HFMEA) is a proactive risk management suggested by Joint Commission on Accreditation of Health Organizations (JCAHO) and new Taiwan hospital accreditation. The research used HFMEA to improve respiratory tube care system, and tried to find out the factors damaging the tube security and proposed improvement method, and thereby reducing respiratory tube incident and ensuring the patient safety.
The study was conducted at five respiratory care units in one regional teaching hospital of central Taiwan. The research team used respiratory tube care proceedings as analysis axis. The respiratory care system was divided into four proceedings: pre-intubation evaluation, care during intubation, post-intubation care and pre-extubation care. It combined analysis of respiratory tube incident reporting system and found out the possible factors influencing respiratory tube security.
The result discovered respiratory tube care proceedings had sixty seven items of potential failure mode and one hundred and thirty three failure factors. There were twenty six items of failure mode and thirty five potential failure factors having high risk coefficiency. These had the priority to use decision tree analysis to intervene on the improvement. These items of potential failure mode included uncooperative clear patient, no evaluation of sedative use, mistake in evaluation and dosage of sedative, mistake in restriction method, physical or mental discomfort of restricted patient, tube placing at wrong position by nursing personnel, wrong fluid volume in the humidifier, abnormal alarm condition not corrected by nursing personnel, poor communication between doctor and nurse, no standard ventilator weaning protocol, no regular evaluation of appropriateness of ventilator weaning settings, etc. We also proposed the improvement programs on patient physical and behavior factor, work flow design and status factor, personal factor of medical personnel, personnel communication factor.
The research used t-test to evaluate the intervention on respiratory tube incidence rate (p=0.028) and ventilator-associated pneumonia (p=0.034). These results had statistical significance. The results could provide medical institute with reference on the maintenance of respiratory tube security.

並列關鍵字

Healthcare Failure Mode and Effects Analysis ； respiratory tube security

參考文獻

陳建誠（2005）。建立醫藥物流作業流程FMEA模式。碩士論文，中原大學，全國博碩士論文資訊網，094CYCU5030029。

張銘智(2007) 。運用醫療失效模式與效應分析於住院給藥流程安全評估。長榮大學醫務管理學研究所碩士論文。台南縣。

財團法人醫院評鑑暨醫療品質策進會（2006）。2006 年度台灣病人安全通報系統年度成果報告。

財團法人醫院評鑑暨醫療品質策進會（2009）。由病人自拔管路事件探討以病人為中心的照護。台灣醫界，52(6)，20-23。

薛亞聖、石崇良(2003)，「建立安全的醫療環境－病人安全架構之規劃研究」成果報告，行政院衛生署九十二年度補助研究計畫：計畫執行機構：財團法人醫院評鑑暨醫療品質策進會。