運用醫療照護失效模式與效應分析（HFMEA）來提升影像醫學科電腦斷層檢查安全

Improved the Security of Computer Tomography Examination by Using Healthcare Failure Mode and Effects Analysis (HFMEA) in the Department of Radiology

丁詩偉(Shih-Wei Ding) ； 黃慧玲(Hui-Ling Huang) ； 游耀芳(Yao-Fang Yu) ； 蔡宜芳(Yi-Fan Tsai) ； 劉慧菁(Hui-Ching Liu) ； 李尉琦(Wei-Ci Li) ； 朱惠珍(Hui-Chen Chu) ； 李宗憶(Zong-Yi Li) ； 石明誠(Ming-Chen Shih)

《臺灣醫事放射期刊》 3卷1期 (2015/03) Pp. 23-31

https://doi.org/10.6717/JTMRT.201503_3(1).0004

摘要

醫療照護失效模式與效應分析（Healthcare Failure Mode and Effects Analysis，簡稱HFMEA）是醫療界採行的一種前瞻性、預防式的系統風險分析工具，最大的特色是對醫療作業流程做出全面性的風險管理，避免不良及異常事件的發生，同時協助醫療管理者面對問題時處理之優先順序，改善相關之制度與作業流程。本篇研究將HFMEA 導入影像醫學科電腦斷層檢查的作業流程，針對電腦斷層檢查各流程步驟進行分析，發掘其潛在的失效模式，評估其嚴重性並決定處理程序，再提出改善對策及追蹤指標，以瞭解HFMEA 應用於電腦斷層檢查安全上的效果如何。研究期間為102 年7 月~102 年12 月，利用醫療照護失效模式與效應分析，從電腦斷層攝影檢查流程中找出32 項失效模式與58 項失效原因，再利用危害指數（Hazard Score，簡稱HS)及決策樹分析，研擬出6 項失效原因優先進行改善，經改善措施實施後6 個月，再評估其危害指數由46 降至19，且之後10 個月（103年1 月~103 年10 月）無任何與電腦斷層攝影檢查流程相關之異常事件發生。因此，從此研究得知，利用醫療照護失效模式與效應分析，可有效改善電腦斷層攝影檢查流程，並提升病人安全。

關鍵字

醫療照護失效模式與效應分析 ； 危害指數 ； 病人安全

並列摘要

Healthcare Failure Mode and Effect Analysis (referred HFMEA) is the medical community to adopt a proactive, prevention-style system of risk analysis tools. The best feature is to make a comprehensive risk management for medical processes to avoid adverse and abnormal events, and help managers prioritize treatment when faced with medical problems and improving related systems and processes. This study will import HFMEA to computed tomography examinations in Radiology for analyzed each process step. To find its potential failure modes, and evaluated the severity for decided the handle processes, and then understood how the effect is applied HFMEA in computed tomography security by proposed improvement countermeasures and track indicators. This study was from July ,2013 to December ,2013, using the failure mode and effects analysis to identify the 32 failure modes and 58 failure causes from computed tomography examination process, and then used Hazard Score (HS) analysis. To investigate and plan forward six failure causes for priority improvement, after six months for improvement measures implemented, the assessment of the Hazard Score was reduced from 46 to 19, and after 10 months (from January, 2014 to October, 2014) there was no any abnormal event associated with computer tomography examination process. Therefore, with this study, we can effectively improve computer tomography examination processes, and improve patients' security by using failure modes and effects analysis.

並列關鍵字

Healthcare Failure Mode and Effects Analysis (HFMEA) ； Hazard Score (HS) ； patients' security