醫療異常事件之分析與探討：以某地區醫院藥物事件為例

Analysis of Medical Incident Events：Based on Medication Errors at one District Hospital

胡麗娟(Li-chuan Hu)

指導教授 ： 陳家聲

國立臺灣大學/管理學院/商學組/碩士(2008年)

https://doi.org/10.6342/NTU.2008.10127

摘要

醫療服務業的組織複雜度比一般企業和製造業高出約20倍，經營管理困難度較高。而醫院為一高風險服務場所，嚴重醫療不良事件的發生及被揭露往往僅是冰山一角。而醫療異常事件的發生常是非單一個人的問題，而是一連串過失所造成，即可用Swiss Cheese Model來解釋。
　　但傳統上醫療過失的發生認為應有人擔責任和被懲罰，所以醫療不良事件通報不足情形很嚴重，估計通報率約為2-6 %，若藉由建立自願、保密、不究責、無懲罰的異常事件通報制度，可藉由小錯誤的提早揭露，來分析、檢討、學習以達到降低及預防醫療異常事件的發生。
　　營造以「病人為中心」的醫療及「重視病人安全」的文化為現今世界醫療潮流趨勢，在台灣醫院評鑑制度對輔導醫院建立內部自願性醫療異常事件通報系統有很大幫助。醫策會也規劃及建立全國自願性外部通報系統(台灣病人安全通報系統)，建構醫療機構間經驗分享及資訊交流的平台。
　　本論文以某地區醫院為例，統計其自民國90年至97年6月間通報共178件醫療異常事件來作分析，在異常事件通報13類型案件中，本人選擇與醫護人員、病人間互動及作業流程高度相關的藥物事件來做分析，以期能找出藥物事件發生原因及改善對策。藥物事件共11件其發生原因為：
(一)、以工作流程因素占大多數：
A.未依標準作業流程(SOP)
B.未做覆核(double check)
C.沒有方便有效方式供工作人員辨識護理之家活動病人身分。
（二）、其次為人員個人因素：
A、照服員幫忙給藥
B、臨床訓練不足
（三）、病人因素：不遵從醫囑服藥
（四）、與藥品因素相關：
A、藥名相似
B、藥物外型或包裝相似
C、藥物有多種劑型
　　藥物事件中有六件為給藥錯誤，其原因較複雜，所以針對給藥錯誤做更進一步根本原因分析以找出原因和預防性措施，主要是要建立屏障，屏障是預防個人、設備、組織以及系統免於傷害的機制，我們應善用屏障以避免醫療異常事件的發生。根本原因分析的結果為：
1.教育訓練有待加強：a.重視病人安全與以病人為中心文化的建立
b.確實執行SOP與double check
2.流程有待改善：a.利用印表機列印病人身分資料貼紙
b.設計注射卡
3.缺少過程面稽核
4.設備待改善：a.應有列印病人身分資料貼紙的印表機及軟體
b.設計防水、柔軟、時尚感的識別手環。

關鍵字

病人安全 ； 醫療異常事件 ； 醫療不良事件 ； 跡近錯失 ； 醫療錯誤 ； 通報系統 ； 藥物事件

並列摘要

The complexity of running medical services organizations is even 20 times greater than that of traditional businesses, enterprises and/or manufacturing firms. Hence the difficulties in the management and operation. The medical adverse events exposed to the public are in fact only an iceberg of a series of incidents. Medical incident events cannot only be attributed to a pure individual problem, but instead a series of medical personnel negligence and wrongdoing. The phenomenon can be illustrated for by the Swiss Cheese Model.
　　Traditionally, personnel involved in medical negligence, flaws and mistakes were deemed liable for sharing administrative responsibility and being imposed punishment. Therefore, under-reporting of cases has become prevalent. Reporting rates of medical adverse events range from 2 to 6％. Provided a voluntary, confidential and non-punitive incident reporting system is established,by detecting minor errors at an early stage,we would be in a much better position to disclose,analyze, examine, inspect, and learn　early enough in order to reduce, prevent and forestall more occurrences of medical incident events.
Building a “patient-centered”environment and “patient safety awareness”culture have now been regarded as the global trend for medical services system. In Taiwan, hospital accrediting or assessing framework help hospitals to establish a sound, voluntary medical incident reporting system. Taiwan Joint Commission on Hospital Accreditation has also planned and built up a nation-wide external reporting system-Taiwan Patient Safety Reporting System（TPR）-as the plateform for the experience sharing among different medical services providers（specifically hospitals）and exchange of information.
　　This thesis takes the case studies from a local district hospital. Analyses have been made spanning the period from 2001 to mid-2008 to locate the causes and remedies for 178 cases of medical adverse events. According to the reporting cases of TPR,of the 13 categories of cases, I chose to analyze the interactions among all medical personnel, patients and closely related medication error, aiming to locate the causes for medication errors and to seek remedial strategy. The 11 cases of medication errors were due to:
1. Work process hiccup
a.Failing to comply with the S.O.P.
b.Failing to do the double checking.
c.Failing to provide convenient and effective ways for working personnel to identify the patients at our nursing home compounds
2. Personnel error/negligence
a. Care-takers or nursing personnel helping to give medications.
b. Insufficient clinical training
3. Patients’fators (failing to take medications as instructed by doctors)
4. Medications-related factors
a. Similar medication names, causing confusion or negligence
b .Similar appearance or packing
c. Various types of medications (injection, oral, etc.)
　　Of the medication errors, six cases were caused by erroneous dispensation of medications. The reason behind this issue was quite complex. We aim to address the problem and seek preventative measures in order to establish a barrier. A barrier is to prevent any personnel,equipment, organization and the system from becoming susceptible to malfunction or harm. We should make good use of the barrier in order to prevent any further occurrence of medical adverse incidents. The outcome of our analysis is as follows.
1. On-job training needs to be reinforced
a. Value the patient safety environment and patient-focused awareness, a culture to be established
b. Ensure that the S.O.P. and Double Checking are fully executed.
2. Work process needs to be improved
a. Use printers to provide patients’IDs,and basic information
b. Design a recording Injection Card
3. Auditing/monitoring during the work process needs to be done.
4. Equipment and facilities need to be upgraded
a. Procure printers that are capable of printing stickers for patients’identification, in addition to applicable software
b. Design a ring or bracelet that is waterproof, soft and fashionable.

並列關鍵字

patient safety ； medical incident event ； medical adverse event ； near miss ； medical error ； reporting system ； medication error

參考文獻

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