運用HFMEA降低麻醉過程氣管內管醫療照護異常率

Applying HFMEA in Reducing the Adverse Event Rates of Endotracheal Tube Placement in Anesthesia

陳信夫(Hsin-Fu Chen) ； 陳秋蘭(Chiou-Lan Chen) ； 林均諺(Chun-Yen Lin) ； 林葦甯(Wei-Ning Lin) ； 何青蓉(Ching-Jung Ho) ； 邱琴瑟(Chin-Se Chiu) ； 林雅婷(Ya-Ting Lin) ； 陳昱甄(Yu-Chen Chen) ； 葉宣德(Hsuan-De Yeh) ； 陳明山(Ming-Shan Chen) ； 謝玉惠(Yu-Hui Hsieh) ； 周俊男(Chun-Nan Chou)

《醫療品質》 10卷1期 (2021/12) Pp. 46-64

https://doi.org/10.29759/THQA.202112_10(1).0003

摘要

麻醉過程的安全性，是手術安全中重要的一環，本院麻醉團隊運用HFMEA的步驟及品管手法來降低「麻醉過程氣管內管照護作業流程」的異常事件發生率。團隊成員透過小組討論找到26項潛在的失效模式與31項潛在的失效原因，後續再運用危害分析矩陣表及決策樹分析，篩選出8個潛在的失效模式及9項潛在的失效原因，並擬定改善行動方案：（一）落實手術前禁食及呼吸道評估、（二）麻醉給藥安全性的改善、（三）改善手術中麻醉維持的給藥、（四）維持麻醉甦醒後呼吸道暢通；經由改善方案介入後，異常事件發生率已由（千分之2.6）降至（千分之1.5）。故醫療照護失效模式與效應分析（Healthcare failure mode and effects analysis, HFMEA）是一種有效的風險管理方法，它可以輔助醫療團隊找出流程中的潛在危害因子，即時採取行動以降低對病人的傷害。

關鍵字

麻醉 ； 氣管內管醫療照護異常率 ； 醫療照護失效模式與效應分析（HFMEA）

並列摘要

The safety of anesthesia is crucial to the safety of surgery. The anesthesia department of Chia-Yi Christian Hospital utilized Healthcare Failure Mode and Effect Analysis (HFMEA) to mitigate the incidence rate of the events in the care of endotracheal tubes during anesthesia. Our team determined 26 potential failure modes and 31 potential failure causes. Afterwards, hazard matrix table and decision tree were utilized to determine 8 failure modes and 9 failure causes. Improvement programs were also constructed as follows: (1) reiteration of preoperative fasting and airway assessment, (2) improvement of the safety of anesthetics administration, (3) refinement of the administration of medications during maintenance, (4) ascertainment of the airway patency during emergence. After the conduction of improvement programs, adverse event rates declined from (2.6 per mille) to (1.5 per mille). Therefore, HFMEA is an effective method for risk management in anesthesia. HFMEA could be applied to determine the potential failure modes and causes, and prompt actions could be adopted to avoid the harm to the patients.

並列關鍵字

Anesthesia ； adverse event rates in the care of endotracheal tubes ； Healthcare failure mode and effect analysis (HFMEA)