頁籤選單縮合
題名 | 運用根本原因分析提升用藥安全=Applying Root Cause Analysis to Promote the Medication Safety |
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作 者 | 廖玲嬋; | 書刊名 | 藥學雜誌 |
卷期 | 35:2=139 2019.06[民108.06] |
頁次 | 頁106-110 |
分類號 | 418.82 |
關鍵詞 | 品質管理; 標準作業規範; 根本原因分析; |
語文 | 中文(Chinese) |
中文摘要 | 由於醫療疏失事件造成的傷害與死亡頻傳,「病人安全」之議題廣泛受到討論與 重視。2015年衛生福利部的病人安全年度目標之一為「提升用藥安全」。凡是人皆可 能發生疏失,減少醫療錯誤、提昇病人安全是各醫療體系改革的重要方向之一。關於 病人用藥,起至藥廠生產藥品、醫師處方、藥師調劑、護理師給藥、至病人使用,環 環相扣,任何一個環節都攸關用藥與病人安全。因此,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,並研擬改善方法,實施後截至目前為止未再發生類似事件,讓我們體 會到以系統概念來處理醫療疏失問題,可以有效改善全院的用藥安全。 |
英文摘要 | Patient safety issues are getting more and more attention due to some serious injuries and deaths, which are caused by medical errors or negligence in recent years. One of our annual goals for patient safety is to “enhance drug safety” in 2015. To err is human. How can we reduce medical errors and improve a patient's safety in a healthcare institute? It has become one of the top priorities. A chain of drug use may start from pharrnaceutical producing, physician prescribing, pharmacist dispensing, nurses distributing, and to the patient consuming. Any errors in the chain will constitute significant threat to the drug safety and the hospital's reputation.With aims to detect and improve systemic defects, Taiwan's accreditation authority has started to promote the use of "Root Cause Analysis(RCA)" since 2004. For education purpose, this case uses RCA technique to identify the underlying factors of a near-miss medication incident. A "tabular timeline" and "why tree ana lysis" were used to determine the root factors of this near-miss incident. This 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 drugs. |
本系統之摘要資訊系依該期刊論文摘要之資訊為主。