應用失效模式與效應分析於組織病理實驗室人為錯誤之研究

人為錯誤是無法避免而又可能導致災難。研究人為錯誤可協助理解錯誤為何發生及如何發生，進而改善品質與效率，防止損害。健康照護組織是複雜而又不透明的系統，醫事人員的錯誤可能傷害病人甚至造成死亡。病理在醫學診斷上扮演重要的角色，組織病理學方面的人為錯誤會對病人造成不良影響。本研究應用失效模式與效應分析(FMEA)於組織病理實驗室作業，並納入Zhang之醫療錯誤分類法以顯示及評估人為錯誤之因素。Zhang之醫療錯誤分類法結合Reason之人為錯誤分類(技巧之疏忽與規則或知識之過失)與Norman之七階段動作理論。工作分析將組織病理實驗室作業分解為七個程序與22個次程序。本研究針對每一次程序之每一動作階段，按照十四個疏忽機轉與十五個過失機轉，得出594個潛在錯誤路徑，並針對每一錯誤機轉提出對策。共有十八個高風險之潛在錯誤路徑亟須預防。全部為與技巧有關之疏忽。大部份是從在實驗室作業之前段並在每個動作之後段。風險最高之作業步驟包括組織檢體之檢查、玻片準備、書寫檢體匣號碼、檢體匣關閉及放置代表性組織塊於檢體匣內。本研究顯示組織病理實驗室作業內與技巧有關之疏忽比與規則或知識有關之過失更具風險性，並顯示作業之前段與動作之後段有較高之人為錯誤風險。本研究修改過之FMEA提供潛在人為錯誤的一個系統性搜尋。標準作業程序應根據FMEA之結果作出修訂。

關鍵字

失效模式與效應分析；人為錯誤；組織病理實驗室

並列摘要

Human errors are inevitable and the consequences may be disastrous. The study of human errors helps us to understand why and how errors arise, thus improving quality and efficiency and preventing damage. Healthcare organizations are complex and opaque systems. Errors committed by medical personnel may result in morbidity or mortality in patients. Pathology plays an important role in diagnosis. Human errors in histopathology may have adverse effects on patients. This study applied failure mode and effects analysis (FMEA), a prospective method, modified with Zhang’s taxonomy of medical errors to reveal and evaluate the factors of human errors in histopathology laboratory operation. Zhang’s taxonomy combined Reason’s classification of human errors (skill based slips and rule or knowledge based mistakes) and Norman’s seven-stage action theory. Task analysis of histopathology laboratory operation was performed and resulted in 7 processes and 22 subprocesses. FMEA was performed for each stage of action in each subprocess with regard to 14 mechanisms of slips and 15 mechanisms of mistakes. A total of 594 potential error steps were found. Countermeasures with respect to each type of error mechanism were proposed. Eighteen potential error steps of high risk were found. They were the most urgent to be prevented. All were skill based slips. Most were in the early phases of laboratory operation and in the late stages of action. Those of highest risk are examination of tissue specimen, preparation of glass slides, writing of number on cassette, closure of cassette, and placement of representative tissue fragments into cassette. This study showed that skill based human errors presents with higher risk than rule or knowledge based human errors in histopathology laboratory operation, and that most skill based human errors were in the initial phase of operation and involved the late stages of action. The modified FMEA in this study provided a systematic search of potential human errors. Standard operation procedure should be revised with reference to the results of the FMEA.

並列關鍵字

Human errors ； Failure mode and effects analysis ； Histopathology laboratory

參考文獻

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應用失效模式與效應分析於組織病理實驗室人為錯誤之研究

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