頁籤選單縮合
題 名 | 重照率的失效性風險評估及預防=Assessment and Prevention of Failure Mode Effects Analysis and Criticality Analysis in Repeated Rate of Radiography |
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作 者 | 錢信德; 王高倫; 蘇振隆; 張榮華; 郭榮富; 張永強; | 書刊名 | 中華放射線技術學雜誌 |
卷 期 | 32:2 2008.12[民97.12] |
頁 次 | 頁155-163 |
分類號 | 419.59 |
關鍵詞 | 失效; 病人安全; FMECA; FTA; FMECA>FTA; Failure; Patient safety; |
語 文 | 中文(Chinese) |
中文摘要 | 醫療器材需要風險管理,醫療行爲更需要風險管理。放射科亦會出現的醫療行爲的失效,以往對醫療行爲的失效原因總是針對單一事件來做檢討,並無法有效的減少事件再次發生的機率。要有效解決這些問題,應朝全面品管著手,我們的研究主要是將失效的原因作成數據,進一步分析造成此一失效的最主要事件,來改善及預防,如此必能大幅降低該事件再次發生的機率。因此,本研究主要目的是想藉用工業界預防失效及評估失效嚴重性的方法,針對改善病人安全的可行性,期望能藉此降低病患再次接受輻射劑量及相關醫療成本的浪費。本文主要是將Fault Tree Analysis(FTA)與Failure Mode Effects Analysis and Criticality Analysis(FMECA)這二種方法嘗試用於病人安全的流程;定義病人需重照時,即爲失效,參考整年的廢片統計數據及現行的檢查流程,將流程分解成十一個步驟來製作系統流程圖和繪製FTA,進一步簡化FTA並找出廢片造成病患重照的原因,最後再將我們分析的結果製作成FMECA,並用FMECA來作預防性失效風險評估。以研究結果來看,我們發現操作人員的技術不純熟(A)造成重照佔所有重照的機率爲49%,並且由計算出失效模式關鍵性質(Cm=0.00016944)得知不當定位(A1)爲A事件最關鍵的單位。因此,我們針對這個問題加以探討及改善,必能大幅改善重照率。我們針對此一事件建議改善的方法有三方面:(一)利用平時對放射師同仁加強教育訓練並請臨床科醫師來對放射師做繼續教育;(二)對新進人員加強訓練儀器的操作,利用數位化技術增進影像的品質;(三)不定期檢測人員之操作之正確性,並納入單位的績效管理指標。 |
英文摘要 | Both medical instrument and medical behavior require risk management. Failures of medical behavior also occur in any department of diagnostic radiology. In the past, we often focused on the cause of any single event in analysis but we could not reduce the repeated rate of the same kind of failure. It is necessary to get overall quality control in order to resolve the problem. We have to obtain numerical data of all possible causes of failure and then analyze and find out the main cause(s) for failure in each event in order to take improvement and prevention. We are then able to considerably reduce the repeated rate of failure. Our purpose of this study is to utilize the method of assessment of the severity of failure of any procedure and its prevention, which is applied in industry, for reduction of exposure of ionizing radiation as an issue of patient safety and for reducing relevant medical cost. We tried to apply the Fault Tree Analysis (FTA) and Failure Mode Effects Analysis and Criticality Analysis (FMECA) in setting up the procedure focusing on patient safety. We defined repeated taking radiograph to be an event of failure. Considering the data of disposed X-ray films and the current procedure of taking radiograph, we divided the procedure into eleven steps in making a flow-chart and then drew FTA which was then further simplified in order to find out the main cause(s) of repeated radiography. Finally, we analyzed the results of FTA and then make FMECA for assessment and prevention of repetition of radiography. The results showed that technical non-acquaintance of technicians (A) in taking radiograph was the main cause (49%) and the crucial factor (Cm=0.00016944) of mispositioning (A1) in FMECA was then calculated to be the most important unit of A. This was the aim of improvement. In conclusion, the most important issue in reducing repeated rate of radiography is improvement of technical acquaintance of technicians, for which we recommend the following methods: (1) enhancement of the update education of technicians with participation of clinicians; (2) enrichment of the freshmen training course in manipulation of instrument and imaging devices or getting digitized images for upgrade of image quality; (3) auditing the accuracy of manipulation for evaluation of personal profit fraction in the department. |
本系統中英文摘要資訊取自各篇刊載內容。