運用根本原因分析手法改善用藥安全性－個案研究

促進病人安全及品質已為醫療機構的重要議題，故醫療團隊亦需學習品質管理運用技巧於照護系統中。醫策會於2004年起大力推動異常事件根本原因分析，重點在於找出系統及組織的缺失，而非對個人譴責。本文以門診皮膚科用藥異常事件進行根本原因分析，對於用藥安全具有極佳的教育意義。透過時間序列表及原因樹分析，發現根本原因為藥品容器外觀相似及置放位置相近，缺乏腐蝕性藥品與一般藥品使用及標示標準作業流程，除了制定標準流程及物質安全資料表，更改藥品的包裝並將腐蝕性藥品分開置放，以降低因環境及流程因素導致犯錯的可能性，並以屏障分析評值改善方案的成效，截至目前為止未再發生類似事件，更將此一改善方案平行展開至全院其他腐蝕性藥品，並統一全院危險藥品的標示，以系統概念來改善醫療疏失問題，有效改善全院用藥的安全性。

關鍵字

根本原因分析；用藥安全；醫療疏失

並列摘要

Implementing new quality management task is critical for healthcare providers to improve quality and safety in their organization. With aims to detect and improve systemic defects, Taiwan's accreditation authority has started to promote the use of ”Root Cause Analysis (RCA)” methodology since 2004. For education purpose, this case study use RCA technique to identify tile underlying factors of a near-miss medication incident in an ambulatory dermatology setting.A ”tabular timeline” and ”why tree analysis” were used to determine the root factors of this near-miss incident. The underlying causes, including drug container location, similarity in package, lacking of standard operating procedure to separate corrosive and generic medicine are indentified. In order to prevent medication errors, we implemented some corrective plans, including standard operating procedures establishment, provision of drug safety information, change of medication package and location. In addition, ”barrier analysis” was used to strengthen the robustness of the corrective plans. This case study was very helpful in identifying weak points in medication processes. To assure medication safety, we believe the strategies developed from this RCA case can further spread to the management for other corrosive drugs.

並列關鍵字

root cause analysis ； medication safety ； medical error

國際替代計量

運用根本原因分析手法改善用藥安全性－個案研究

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