應用RFMEA提高電腦斷層檢查作業安全性之研究

Radiology Failure Mode and Effect Analysis Applied to Improve the Operating Safety of Computed Tomography Examination

劉泰程(Tai-chung Liou)

指導教授 ： 黃麗玲

中臺科技大學/管理學院/健康產業管理研究所/碩士(2012年)

https://doi.org/10.6822/CTUST.2012.00036

摘要

背景：電腦斷層檢查(CT)，存有高劑量輻射致癌與顯影劑不良事件危害的雙重風險，目前仍是醫師重要的第一線影像診斷工具。因此，對於病人安全議題來說，安全的CT檢查作業流程與顯影劑標準篩檢流程，絕對是迫切需要的。
目的：主要是依據放射線醫學失效模式與分析(Radiology Failure Mode and Effect Analysis ,RFMEA)模式建立適當的CT檢查作業查核表(checklist)，幫助放射科人員在CT檢查過程中，有效改善醫療失效行為並預防之，減少病患不必要的輻射暴露與保護醫療從業人員作業上的風險。
方法：收集臺中市某區域教學醫院放射部門2011年2-4月之CT檢查作業流程資料、歷年CT異常事件記錄、顯影劑不良事件統計等資料，配合RFMEA模式做危險係數分析，找出失效關鍵點，以此為基準製作查核表。於2012年2月對放射部門人員進行查核表預試，2012年3-5月正式實施。期間持續搜集人員在實施過程中的問題與資料，並比較分析2011與2012年之CT異常與顯影劑不良等事件發生因素，也參考WHO查核表使用建議，藉此持續修改查核表之內容。另對於人員在檢查過程中作業風險的認知度，也做具體的調查。
結果：本查核表每月篩檢出異常醫療作業事件70件以上，過敏發生比率經同期比較2011年與2012年，由0.67%下降至0.24%，滲漏比率由0.52%降至0.18%，員工作業風險係數認知(RPN)由預試前898.08分高風險，2個月後下降至160.02分，使用後員工病人安全認同度由824.61分提升到989.23分。checklist施行有效避免醫療事件的發生與提升醫療間溝通的能力，也藉此讓檢查流程更加安全，並提升病人安全及醫療影像作業品質。

關鍵字

病人安全 ； 失效模式與分析 ； 電腦斷層檢查 ； 查核表

並列摘要

Background: Computed Tomography (CT), an important first line of diagnostic imaging tool for the doctors, clearly exists a double risk of radiation and the contrast medium hazards. Therefore, for patient safety issues, appropriate management of CT scan and contrast medium standard screening tool is absolutely urgently needed.

Purpose: According to the Radiology Failure Mode and Effect Analysis (RFMEA), we created an appropriate checklist of CT scan operating to help radiologists to find out or to prevent medical failure in the inspection process. So that, it can reduce patients’ unnecessary exposure and protect medical practitioners.

Methods: To collect the data of CT scan processes, CT abnormal event log over the years, the contrast medium adverse event statistics from the Radiation Medicine department of a regional teaching hospital in Taichung City from February to April in 2011. To create a checklist by the analysis of the risk coefficient with RFMEA mode, to find out the key point of failure. Checklists tests of Radiation Medicine department staff on February 2012, were formally implemented from March to May in 2012. In addition to collect the relevant processes and data, we did the comparative analysis of the occurrence factors of CT abnormalities and contrast medium adverse events in 2011 and in 2012 during this time. We also refer to the WHO check list of recommendations to continue to modify the contents of the checklists. In addition, we do the investigation about the awareness of operational risk in the inspection process.

Results: Results: This checklist is a monthly screening abnormalities medical jobs event more than 70. Allergy ratio by over the same period in 2011 and 2012, fell to 0.24 percent from 0.67 percent, the leakage rate from 0.52 to 0.18, the staff operational risk factorcognitive (RPN) from 898.08 points in the pre-test high-risk, two months later fell to 160.02 points, after use the degree of recognition of staff, patient safety upgrade from 824.61 points to 989.23 points. The checklist effectively prevent the occurrence of medical events and enhance the ability to communicate between the medical units, but also to make the inspection process more secure, enhance patient safety and medical imaging quality .

並列關鍵字

FMEA ； Patient safety ； Computed Tomography ； checklist

參考文獻

周琮霖、簡志強、蘇世斌(2010)。臨床醫學影像檢查用顯影劑之腎毒性探討。家庭醫學與基層醫療，25(5) ，183-187。

閻紫宸 (2008)。放射科如何落實病人安全。醫療品質雜誌，2(5)，63-66。

吳美儀、簡竹君(2006)。顯影劑腎病變。腎臟與透析，18(4)，166-169。

古雪鈴、王拔群、陳雅惠、陳怡如、朱文慧、蕭富仁(2006)。手術室醫護人員對使用「病人安全辨識查檢表」之態度調查。醫療品質，3(2)，1-9。

林明賢(2004) 。注射顯影劑攝影標準作業流程。北市醫學雜誌，1(4)， 216。