臺灣癌症化療住院病患用藥安全的潛在失效原因分析

目的：本研究係以醫療失效模式與效應分析為分析工具，探討住院化學治療病患可能面臨之潛在失效原因，並對潛在失效原因提出可行之改善方法。方法：本研究針對住院化學治療藥物之用藥過程，藉由小組成員的討論以及實地流程觀察與分析找尋出潛在失效因子，並針對潛在失效因子以決策樹分析找出其應首當改善項目並給予其改善方法。結果：透過醫療失效糢式與效應分析，找出12個子流程、38個潛在模式、161個潛在失效原因，並針對其失效原因提出建議。結論：此種具系統性與連續性的前瞻性風險分析方法目的就是希望在危害尚未造成前便可因流程改善而避免，可有效提高醫療品質確保病患安全。

關鍵字

病患安全；用藥安全；化學治療；醫療失效模式與效應分析

並列摘要

Objectives: This study aimed to identify the potential causes of care failures for the chemotherapy patients, using the analytical tool of Healthcare Failure Mode and Effect Analysis. It also recommends corrective actions to improve the patient in chemotherapy care process. Methods: The medication processes of chemotherapy patients in one regional hospital in central Taiwan were explored in this study. A multidisciplinary team included pharmacists, nurse, information technologist, hospital management advisor and assistant. The team used Hazard Analysis and Decision Tree Analysis to identify the failure modes that need to be improved. Results: With the HFMEA technique, 12 sub-processes, 38 potential failure modes and 161 potential causes of failure points in the medication process of the chemotherapy were identified. To solve these problems, we used E-learning in Pharmacist education and trainings, established the Medication bar-code system in information system and standardized the chemo-drug dispensing process. Conclusions: So far, there was no medication incident after the process was improved. Prospective risk analysis tools like Healthcare Failure Mode and Effect Analysis could help healthcare workers to identify the possible pitfalls in patient care and to improve quality of care and patient safety effectively.

並列關鍵字

Patient safety ； Medication safety ； Chemotherapy Healthcare Failure Mode and Effect Analysis (HFMEA)

被引用紀錄

胡寶雪、胡曉珍、黃惠如、趙慧玲、雷宜芳（2014）。運用失效模式與效應分析改善手術室病理檢體採集送檢流程及退件率。護理雜誌，61(2)，50-59。https://doi.org/10.6224/JN.61.2S.50

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臺灣癌症化療住院病患用藥安全的潛在失效原因分析

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