- 期刊
運用RCA於病人安全管理
The Application of Root Cause Analysis in Patient Safety Management
摘要
近年病人安全日益受到重視，許多研究顯示醫療環境中存在著相當程度的危險，醫療疏失除了造成病人的傷亡也帶來巨額的賠償。護理人員是醫療團隊成員之一，擔負著病人照護很重要的角色，一旦某一重大異常事件發生，醫院決定要進行根本原因分析（root cause analysis，簡稱RCA）後，大家就開始互推責任，相互指責，護理人員很容易成為眾矢之的。由於對RCA的認識不足以及缺乏運用經驗，RCA自調查一開始就給大家帶來極大壓力，有些護理人員甚至於調查尚未結束就選擇離開職場，殊為可惜。本文主要介紹什麼是RCA、那些事件需進行RCA、如何進行RCA、異常事件決策樹的運用、RCA的優缺點。期盼大家對RCA有更多瞭解，焦點集中於系統流程，非探討個人問題，建立一個不易犯錯的環境，營造「學習預防再發生」代替「責怪懲罰』的文化，以提升醫療從業人員對病人安全管理的能力。
並列摘要
Patient safety gained special attention in recent years after numerous studies revealed that unsafe practices existed in healthcare institutions. Medical negligence results in not only unnecessary pain, suffering and sometimes death of the patient, but also financial burden from lawsuits to the healthcare institution. After a major adverse event occurs, hospitals usually conduct a root-cause analysis (RCA) to find ways to improve quality of care. Unfortunately, the finger-pointing often starts before the RCA even begins, and nurses become easy targets in the blaming circle. Due to lack of knowledge and experience in RCA, some nurses feel the blaming pressure unbearable and they choose to leave the institution before the RCA is concluded. This article discusses indications, how to conduct an RCA, and how to use unusual occurrence decision tree, and the pros and cons of conducting RCA. Nurses need to understand that to produce a safe patient care environment, the RCA focuses on correction of the system instead of on individual mistakes. To elevate the healthcare workers, competency in patient safety, it is necessary to replace the blaming with a ”learn how to prevent errors from happening again” culture.