運用醫療照護失效模式與效應分析來提升放射治療安全度

放射治療因其複雜過程有其潛在的危險性，包括人為操作、機器限制及病患狀態等。病人安全為醫療照護品質中重要的一環，透過有效的危害分析方式，以降低放射治療過程中錯誤發生機率為各醫院所必須。醫療照護失效模式及效應分析(healthcare failure mode and effect analysis, HFMEA)為一前瞻性的分析方式，藉此評估放射治療中的危險因子，並鑑別放射治療過程中潛在的失效步驟，再與以改進。本單位HFMEA團隊針對放射治療的流程進行分析，包括定義每日放射治療流程項目及評估流程中潛在失效原因，再利用決策樹決定優先處理之潛在失效模式項目，最後藉相關改善措施以降低失誤的發生。本研究以危害指數的方式分析，共4項失效模式列為優先處理，經修正及改善後，危害指數降低率為33.3%、75%、50%及50%。主要改善措施包含(1)放射師執行治療前確實核對病歷醫囑，確保病人治療姿勢、治療計畫及與治療相關設定正確無誤。(2)放射師在執行影像驗證時進行初步判讀，以減低治療時因擺位誤差，對劑量的給予造成不均。(3)藉由增設硬體及軟體設備，降低放射治療過程中安全的疑慮。期許透過HFMEA之分析方式，降低放射治療療程中失效機率的發生，提升整體病人安全。

關鍵字

放射治療；醫療照護失效模式及效應分析；危害指數；病人安全

並列摘要

Radiotherapy process is regarded as potentially risky for patients because of its complex processes, operation by people, limit of machine and patient’s condition. Patient safety is one of the main components in quality of health care. For patient safety, an effective risk analysis method to reduce error rates of the radiotherapy process should be prioritized in hospitals. To evaluate risk in the radiotherapy process using a proactive risk analysis method. Healthcare failure mode and effect analysis (HFMEA) was adopted to identify potential radiotherapy process failures. The HFMEA team is formed to identify, evaluate, and prioritize potential failure modes based on a radiotherapy process flowchart. Subsequently, a decision tree is used to locate potential failure modes requiring urgent improvement. Finally, some recommended actions are generated and executed to eliminate possible risks. In our study, total of 4 failure modes were identified with high hazard scores in radiotherapy processes. The improve rate of risk priority number (RPN) were 33.3%, 75%, 50% and 50% after improvement. There are some ways to eliminate potential risk in radiotherapy including check medical orders and review images before treatment. HFMEA is a useful tool to evaluate potential risk in radiotherapy processes and promote patients safety.

並列關鍵字

Radiotherapy ； HFMEA ； Risk Priority Number ； Patients Safety

國際替代計量

運用醫療照護失效模式與效應分析來提升放射治療安全度

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