運用根本原因分析改善病人手術安全之個案研究

Using Root Cause Analysis to Improve the Safety of Surgical Patients: A Case Study

張麗君(Li-Chun Chang) ； 蔡宗益(Tzung-Yi Tsai)

《輔仁醫學期刊》 5卷3期 (2007/09) Pp. 133-142

摘要

本研究以發生於某醫學中心手術室開錯部位幾近錯誤(near miss)個案為例，以根本原因分析手法探討隱藏在手術流程中的潛在風險，釐清其根本原因。經時間序列表與因果原因樹分析後發現，此幾近錯誤之根本原因為：(1)人員電腦技巧不佳，(2)無手術病人、術式及部位確認之標準作業流程，(3)醫護人員欠缺重視病人安全之觀念。除參酌文獻建議、單位特性與人員編制，針對不同根本原因擬定合適的改善方案外，並以屏障分析評值各方案之效度。此個案研究不僅助於發掘隱藏於手術流程中的風險，提早擬定因應措施外，根本原因分析運作手法更可作為提昇醫療品質之實務參考。

關鍵字

根本原因 ； 病人安全 ； 個案研究

並列摘要

This case study used Root Cause Analysis (RCA) to identify the underlying factors of a near miss of wrong-site surgery that occurred in a medical center in Taiwan. We used a tabular timeline and event-and-casual-factor tree analysis to determine the 3 root factors of the near miss, which included bad computer skills, no standard operating procedures for preventing wrong patient, wrong procedure, or wrong site surgery, and a lack of alertness to patient safety among healthcare workers. In order to prevent wrong-site surgery, we formulated some corrective plans according to former study suggestions, unit characteristics, and worker numbers. In addition, we used a barrier analysis to strengthen the reliability of the corrective plans. This case study was very helpful in identifying common weaknesses in the operative procedures and formulating useful strategies. The process of RCA can be applied as a practical reference to improve the quality of health care.

並列關鍵字

Root Cause Analysis RCA ； patient safety ； case study