運用醫療照護失效模式與效應分析提昇檢查室及放射科檢查轉送安全

Improvements in Transport Safety Using Healthcare Failure Mode and Effect Analysis in the General Examination Room and Radiology Room

陳庭妤(Ting-Yu Chen) ； 蔡季芸(Chi-Yun Tsai) ； 林虹束(Hung-Shu Lin) ； 辜漢章(Han-Chang Ku)

《醫學與健康期刊》 9卷2期 (2020/07) Pp. 63-72

摘要

本專案採用醫療照護失效模式與效應分析（Healthcare Failure Mode and Effect Analysis, HFMEA）模式進行跨部門間的風險管理，以改善某區域教學醫院檢查病人轉送流程，降低轉送安全異常率及改善病人危害嚴重度。依據HFMEA模式進行分析，主因為送檢前病人準備不齊全、轉送人員未確實執行病人辨識、轉送流程規範不齊及無稽核機制、資訊系統功能不足；故加強人員教育訓練及落實病人辨識、修訂轉送流程規範及建立稽核制度、建構轉送安全交班資訊化系統以利即時聯繫。回溯2016年轉送檢查異常事件，篩選出19項潛在失效原因，執行改善後高風險因子降為2個，轉送安全異常率降至0.02%，病人危害三級嚴重度降至15.4%。透過此專案推展可降低病人檢查轉送安全異常率及危害嚴重度，亦可維護病人安全及提升照護品質，以避免重大風險發生。

關鍵字

醫療照護失效模式與效應分析 ； 轉送安全 ； 檢查

並列摘要

We conducted a healthcare failure mode and effect analysis (HFMEA) to improve the safety of patient transport in the general examination room and radiology room at a southern regional hospital in Tainan City, Taiwan. We also sought to reduce rates of reported abnormalities in patient safety in the hospital's notification system and improve the patient hazard severity. To do this, we strengthened personnel education training, implemented patient identification practices, revised the norms of transport process establishing an audit system, and constructed a transport safety shift information system to facilitate timely communication. To evaluate the outcomes, we reviewed the transport safety abnormal events in 2016 and screened them for 19 potential causes of failure. After the improvement measures were implemented, the risk factors for high risk decreased to 2, rate of reported patient check and transfer safety abnormalities was reduced to 0.02%, and the rate of level 3 hazard severity was reduced to 15.4%. In conclusion, our efforts enabled us to reduce the abnormal rate of patient check, transport safety procedures and hazard severity, which led to better maintenance of patient safety and improved quality of care. Our efforts led to a consensus between registered nurses and transfer personnel regarding the best way to ensure transfer safety protection and improve and maintain patient safety by avoiding major risks.

並列關鍵字

Healthcare failure model and effect analysis ； Transport safety ； Examination

參考文獻

王玫瑛、蘇經凱、陳正昇：運用HFMEA改善檢驗危急值通報回覆率。醫療品質雜誌 2015；6：16-27。Wang MY, Su CK, Chen CS: Using Healthcare Failure Mode and Effect Analysis to Improve the Reply Rate of Medical Examination Critical Value Notification. Healthcare Quality 2015;6:16-27. [In Chinese]

衛生福利部：107-108年度醫院病人安全工作目標及執行策略。http://www.patientsafety.mohw.gov.tw/Content/zMessagess/contents.aspx?&SiteID=1&MmmID=621273300317401756&MSID=777752343551741053。引用11/30/2018。Ministry of health and welfare, Taiwan, ROC. (2018). Annual Hospital Patient Safety Goals and Strategies for 2018-2019. Available at: http://www.patientsafety.mohw.gov.tw/Content/zMessagess/contents.aspx?&SiteID=1&MmmID=621273300317401756&MSID=777752343551741053. Accessed November 30, 2018. [In Chinese].

衛生福利部台灣病人安全資訊網：台灣病人安全通報系統2016年TPR年報。http://www.patientsafety.mohw.gov.tw/Content/Downloads/List01.aspx?SiteID=1&MmmID=621273303702500244。引用1/10/2018。Ministry of Health and Welfare (Taiwan, ROC). Taiwan Patient-safty Reporting System: Annunal TPR Report 2016. Available at: http://www.patientsafety.mohw.gov.tw/ebook/20170726/mobile/index.html#p=1. Accessed January 10, 2018. [In Chinese].

洪秀琴、蔡美菊、林月娥、陳昕霓：提升頭頸部腫瘤氣切病人轉送過程之完整性。腫瘤護理雜誌 2014；14：37-51。Hung HC, Tsai MC, Lin YE, Chen HN: Safeguarding the Patient Safety during Transfer of Head and Neck Cancer Patients with Tracheostomy. The Journal of Oncology Nursing 2014;14:37-51. [In Chinese]

劉淑倩、陳曉雯、姜美夙、陳婉宜、郭美玲、莊靜娟：提昇某外科病房護理人員執行轉送作業溝通之有效性。長庚護理 2014；25：42-54。Liu SC, Chen HW, Chiang MS, Chen WY, Kao ML, Chuang CC: A Project to Enhance Transfer Operations Effectiveness of the Communication between the Nursing Staff of a Surgical Ward. Chang Gung Nursing 2014;25:42-54. [In Chinese]