- 期刊
人為因素分析歸類系統（HFACS）簡介以手術器械滅菌品質為例
Introduction to Human Factors Analysis and Classification System (HFACS) An Example of the Sterilization Quality of Surgical Instruments
摘要
本文介紹了人為因素分析歸類系統（HFACS）及其在手術器械滅菌品質領域的應用。HFACS是一個從人為因素角度分析事故原因的工具，源於James Reason的瑞士乳酪模型，將人為錯誤分為四大類：不安全行為、不安全行為的前置狀況、監督因素和組織影響。醫療版HFACS用於醫療環境，幫助識別導致醫療錯誤的根本原因，促進病人安全和醫療品質的提高。舉例而言，將HFACS應用於手術器械的滅菌品質分析以識別影響滅菌品質的多層次因素，有助於擬定改善策略。同時本文亦強調HFACS對領導和管理的重要性，它有助於提高組織的安全文化、預防事故並促進持續改進。雖然HFACS具有結構化分析、全面性和提高安全意識等優點，但其有效性高度依賴於資料品質，且存在主觀性和培訓要求等限制。本文最後強調，為了最大化HFACS的效果，需要關注資料品質、減少主觀性、提供足夠的培訓，並克服實施改進措施時的挑戰。
並列摘要
The article introduces the Human Factors Analysis and Classification System (HFACS) and its application in the field of surgical instrument sterilization quality. HFACS is a tool for analyzing the causes of accidents from a human factors perspective, based on James Reason's Swiss Cheese Model. It categorizes human errors into four main categories: unsafe acts, preconditions for unsafe acts, supervisory factors, and organizational influences. The medical version of HFACS is used in healthcare environments to help identify the root causes of medical errors, promoting patient safety and improving medical quality. For example, applying HFACS to the analysis of sterilization quality of surgical instruments identifies multiple factors affecting sterilization quality, which aids in the formulation of improvement strategies. The article also emphasizes the importance of HFACS for leadership and management, as it helps to enhance organizational safety culture, prevent accidents, and promote continuous improvement. However, despite the advantages of HFACS, such as structured analysis, comprehensiveness, and enhancing safety awareness, its effectiveness is highly dependent on the quality of data and is subject to limitations such as subjectivity and training requirements. The article concludes by emphasizing that to maximize the effectiveness of HFACS, attention needs to be paid to data quality, reducing subjectivity, providing adequate training, and overcoming challenges in implementing improvement measures.