運用失效模式與效應分析技術及資訊科技改善用藥安全

中文摘要研究目的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。多種因素會造成給藥錯誤，其中包括醫療人員的溝通不良，知識缺乏及執行過程的缺失。在醫院中醫療人員原被期望是扮演保護病人的守護者，因此如何有效防止給藥錯誤，早成熱門議題並且已有相當多的文章探討此問題。本研究目的在運用醫療失效模式及效應分析(FMEA)評估護理人員給葯流程潛在風險因子，並提出改善病人給葯安全之可行性方案。並運用醫療資訊技術建立一套教育系統，以期提供醫療人員即時正確的訊息以及決策輔助工具更加確保病人用藥的安全，另一方面也利用資訊技術去發掘給藥過程的不良給葯事件或幾近失誤的事件，作為改善及學習的依據。研究方法採類實驗研究做研究前、後比較法。採立意取樣，以27位到個案醫院三個月內的新進護理人員及143位資深護理人員為對象進行收案。運用FMEA系統性風險評估方法來分析給葯安全流程上，並找出可行的介入方案。經FMEA分析後將以電腦資訊系統做研究介入。研究結果因為5位新進人員不到三個月離職，因此共有22位新進護理人員，及143位資深護理人員接受電腦藥物教育系統及給藥輔助葯物辨識系統的介入，同時以電腦拍攝方式做為給藥流程最後的監控。前測研究結果顯示護理人員對能了解自己照護的病患每一種葯的交互作用(2.54?b0.56)及葯物的安全劑量(2.52?b0.64)的知識及自信度(6.70?b2.11) 分數最低，在給錯葯的因素分析以葯物的外觀相似(4.0?b0.71)及醫囑處方簽字跡潦草(4.04?b0.72)得分最高。經由電腦資訊系統的藥物教育及給藥流程輔助並監測後，在後測研究結果顯示，給葯安全認知(36.0?b2.85 vs 40.33?b4.09)有顯著性的提昇，達統計上顯著的差異(p＝0.012)。給葯自信上(102.13?b15.03 vs 117.13?b14.39) 也達統計上顯著的差異(p＝0.001)。在給物電腦輔助辨識系統，及教學系統使用後，研究結果顯示護理人員給錯葯的件數下降為0 (為測試個案單位拍照葯物照片與原始醫囑比對結果)。討論與建議研究結果有顯著成效的關鍵，是在有效的運用失效模式，找出可能失效的流程，並發展出一套有效的電腦資訊教育系統及給藥監測系統做即時的介入。本研究結果除了增加給葯時護理人員對自己給葯更有認知及自信外，在電腦辨識系統的輔助下降低給藥的錯誤件數，因而增加病人的安全。本結果可提供為其他醫院或部門，作為降低醫療失誤的預防及監測的參考，以增加病人的給藥給藥安全。關鍵詞: 失效模式與效應分析、用藥安全、資訊科技

關鍵字

失效模式與效應分析；用藥安全；資訊科技

並列摘要

Abstract Background Reducing medication errors and improving patient safety have become major issues in hospital management. Medication errors occur for a variety of reasons, including inaccurate communication and deficits in knowledge and performance by and among all health care professionals. Health care professionals can play an important role in protecting patients from adverse effects of medication errors. Therefore, the aims of this study were applying failure mode and effects analysis (FMEA) to enhance the safety of medication administration by implementing computerized education system and E-processing of bed side medication administration. Materials Qui-experimental (before and after) design was used in this study. 27 new nurses (employeed under three months in the hospital) and 143 nurses were recruited from the case hospital. Using FMEA to identify problem areas and develop computerized process to prevent medical errors as the main intervention methods. Results During the 3 months study period we conducted a total of 22 new employed nurses and 143 nurse who undertook tests of correct identification of medication in a e-learning system. Expect 5 new nurses quit their job during this time. The pilot results showed that nurses’ perspective of lower medication scores were drug interaction (2.54?b0.56)、 knowledge about max. safty medication dosage (2.52?b0.64) and confidence in medical administration (6.70?b2.11). The highest scores of factors of medicine errors were feature similarity (4.0?b0.71) and reading difficulty of prescription (4.04?b0.72). Post test results showed that the knowledge about pharmacology was significantly increased after intervention program (36.0?b2.85 vs40.33?b4.09; p＝0.012). The confidence of medicine administration was significantly increased after intervention program (102.13?b15.03 vs 117.13?b14.39; p＝0.001)。The results of E-learning and E-process improvment decreased medicine errors to zero. This study showed significant improvement in medication safety through FMEA application and computerized medication education. Conclusions Success in achieving significant changes was associated with effective processes and appropriate choice of intervention. Successful teams were able to define, clearly state and relentlessly pursuer their aims and intervention processes. The finding of this study may help hospital administrators to apply FMEA method in preventing medication errors and other areas concerning patient safety. Key words: failure mode and effects analysis (FMEA), medication safety, IT and medication administration