以醫療失效模式與效應分析 改善臨床人員用藥安全之應用-以某X醫院為例

The Application of Healthcare Failure Mode and Effect Analysis Tool in Improving Patients Safety from Reducing Medication Errors A Case Study of X Hospital

趙維明(Way-Mine Jhun)

指導教授 ： 鄭雅穗

元智大學/管理學院/管理研究所/碩士(2009年)

摘要

藥物治療是所有醫療照護方法中，最常被採用的方式，同時護理人員為醫療最前線，給藥醫療照護項目主力皆由護理人員擔任。因此，也增加護理人員發生錯誤的風險率，用藥過程之安全性自不容忽視。研究生擔任護理主管多年，所以研究生迫切希望能在給藥流程管理上尋求避免人為因素或環境產生的疏失及關鍵因素，而給藥異常事件多半直指為人為因素，因此若能應用有效方法控制臨床各個醫事單位在給藥行為流程管理上，防範失效因素發生，相對必能減少因給藥錯誤醫療不良事件發生，同時也提升院內病人安全，及醫療品質。
病人安全近年來受世界各國的重視，尤其以病人用藥安全為重要議題。失效模式與效應分析雖已廣泛被用於航空業、工業界、甚至保險業及倉儲等風險管哩，但卻顯少用於醫療服務；本研究目的在運用醫療失效模式及效應分析(FMEA)評估給葯流程潛在風險因子，並結合給藥前、給藥中、給藥後流程以人、機器、材料、制度、環境等面項發現及探討給藥錯誤因素，提出改善病人給葯安全之可行性方案，並持續追蹤改善成效。
因此，期望藉由此篇研究，能進一步檢視個案醫院內部作業情形，全面檢討用藥安全並建立用藥疏失預防，使每個病患能有安全、有效的醫療環境，。

關鍵字

失效模式及效應分析；病人安全；給藥錯誤

並列摘要

Among all medical treatments and patient care, the pharmaceutical medication therapy has been used most often, wherenurses are on the front line in providing medical drug therapy. Since most of medical drug delivery procedures are done by nurses at the hospital, the mistake risk done by nurses is certainly higher than other staffs. As a nurse chief for many years, the postgraduate student is urgent on seeking methods to reducing human miscarrying factors or environmental effects on medical treatments and managements.
Most of the medication errors come from human factors. In all medication units, if an effective method can be used to control the drug delivery procedure as well as to reduce the failure factor; it will certainly decrease the medical mistake from drug delivery mistake. It will finally increase all patient safety and domestic medical quality.
Recently the patient’s safety becomes very important globally, especially in the drug delivery topics. Failure Mode and Effect Analysis though has already been used in industry routinely. It is rarely used in medicine field yet.
The purpose of this study is to apply the Failure Mode and Effect Analysis (FMFA) to medicine field to assay the potential drug delivery risk factors. Accordingly in this research, it will be used to analyze all possible potential risk factors in terms of human, machines, material and the environmental system. This study also brings up a proposal to improve the safety of drug delivery, and persist in improving its availability.
It is expected that this study to be helpful in surveying the safety management situation inside a hospital. It also helps in reviewing the drug application safety and setting up a drug medicine mistake prevention system, such that patients willreceive much safer and more effective therapy.

並列關鍵字

Failure Mode and Effect Analysis (FMFA)； patient safety ；medication errors

參考文獻

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