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題名 | 運用HFMEA提升用藥安全=HFMEA Improving Patient Safety |
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作者 | 陳華鑫; 黃崇濱; 郭集慶; 林政杰; 于素珍; | 書刊名 | 藥學雜誌 |
卷期 | 28:4=113 2012.12[民101.12] |
頁次 | 頁116-121 |
分類號 | 418.1 |
關鍵詞 | 醫療失效模式與效應分析; 危害指數; |
語文 | 中文(Chinese) |
中文摘要 | 目的:期望藉由醫療失效模式與效應分析 (healthcare failure mode and effect analysis; HFMEA)修改化療給藥流程,以提升癌症病人用藥安全。 方法:參考美國退伍軍人部制定之 HFMEA步驟,就藥事作業流程來定義主題、成立團隊、繪出流程圖、進行危害指數 (hazard score; HS)評估、決策樹分析與找出失效原因提出改善。 結果:研究期間為 2010年4月至 2011年9月,從化療給藥流程中找出 87項失效模式與 147項失效原因進行決策樹分析,最後研擬出 12項失效模式與 13項失效原因進行改善。在改善措施介入後 (2011年4月1日至 9月30日),其醫令疏失率 (0.1278%,3件)與調配疏失率 (0.0426%,1件)均較去年同期 (2010年4月1日至 9月30日)醫令疏失率 (1.4500%,30件)與調配疏失率 (0.1450%,3件)明顯下降,其改善幅度分別為 91.19%與70.63%,且並未有化療給藥疏失。在進行流程改善後,專案小組將原先的失效模式再進行一次危害指數評量,其危害指數在改善後均下降 (HS ≤ 2分)。 結論:從我們的研究得知,運用 HFMEA風險管理工具,能有效的改善化療處方、調配和給藥流程,並提升癌症病人用藥安全。 |
英文摘要 | Objective: Applying healthcare failure mode and effect analysis (HFMEA) to increase the patient safety of chemotherapy. Methods: This study used HFMEA method for identifying problems of chemotherapy process. The processes of HFMEA are as follows: 1. defining the topic 2. assembling a multidisciplinary team 3. graphically describing the flow chart 4. conducting a hazard score analysis 5. decision tree analysis 6. outcome measures. Results: During the period of study (from Apr 1, 2010 to Sep 30, 2011), we found 87 failure modes and 147 potential causes from chemotherapy processes. There were 12 failure modes and 13 potential causes were identified by decision tree analysis. During the period of our intervention (from Apr 1, 2011 to Sep 30, 2011), the medication errors significantly decreased. The percentage of the prescribing errors and dispensing errors were 0.1278% (3 events) and 0.0426% (1 event), respectively. The HS of previous 13 probability failure modes dropped (HS≤2). Conclusions: Our study showed that HFMEA technique effectively improved the chemotherapy proceses and significantly increased the patient safety. |
本系統之摘要資訊系依該期刊論文摘要之資訊為主。