應用「醫療照護失效模式與效應分析」於癌症患者電腦斷層與磁振造影檢查之影像報告品質提升

Applying Healthcare Failure Mode and Effects Analysis in the Improvement of Image and Report Quality of Computed Tomography Scan and Magnetic Resonance Imaging for Cancer Patients

劉時佐(Shi-Zuo Liu) ； 何淑熏(Shu-Hsun Ho) ； 何子龍(Tsu-Lung Ho) ； 李垣林(Yuan-Lin Lee)

《Journal of Radiological Science》 36卷3期 (2011/09) Pp. 57-64

https://doi.org/10.6698/JRS.201109_3603.11

摘要

影像學的正確診斷是擬定癌症治療計畫重要的一步，因此應用系統性的分析方法，提高癌症影像報告品質十分重要。醫療照護失效模式與效應分析（HFMEA）是目前醫療界採行的一種具前瞻性與結構性的系統風險分析工具，此方法的特色是可對醫療作業系統做出全面性的探討，協助醫療管理者面對問題時決定處理優先順序，改善相關制度、技術、工具或方法，避免不良事件的發生。本研究以HFMEA導入中部某區域教學醫院的放射診斷科，按照HFMEA的五個步驟，分析癌症患者所做的電腦斷層與磁振造影檢查之影像報告流程，找出流程內最需要改進的失效模式與原因，擬定對策與改善方案。研究結果為必須針對臨床資訊面、影像品質面、影像判讀面、影像輸入面與回饋機制面等五個方面擬定對策與改善方案。本研究亦顯示HFMEA可以有系統的找出流程中的潛在問題、建立團體共識、改善制度缺失、減少錯誤發生、並增加組織承擔錯誤的能力，以達到提升病患安全與醫療服務品質的目的。

並列摘要

The correct imaging diagnosis is important to cancer patient treatment. It is important to conduct systematic analysis in order to improve the quality of imaging reports. Healthcare Failure Mode and Effects Analysis (HFMEA) is a prospective and structural risk analysis tool in medical practice. The feature of this method allows further comprehensive investigation of current medial operating system. It can also assist medical institute managers to make prioritized decisions on medical problems by improving relevant systems, technology, tools or methods to avoid the occurrence of harmful incidences.The purpose of this research is to introduce HFMEA into the radiological department in a regional teaching hospital in central Taiwan. By following the five steps of HFMEA, failure modes and causes were identified, which were most crucial in improving the process, developing strategies and improvement programs for cancer imaging reporting process. The result of this research showed that make decision and improvement program should be focus on five aspects as clinical information, image quality, imaging interpretation, image reporting, and feedback mechanisms. This study has shown that HFMEA could find potential problems, establish group consensus, reduce harmful mistakes, and increase accountability of our department. This method can achieve the purpose of improving patient safety and strengthening service quality of medical.