頁籤選單縮合
題 名 | 以HFMEA手法改善自備藥管理作業=Utilization of a Healthcare Failure Mode and Effect Analysis to Optimize the Management of Self-prepared Medicine |
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作 者 | 謝承穎; 蔡佩玲; 莊謹如; 廖玲巧; | 書刊名 | 藥學雜誌 |
卷 期 | 35:4=141 2019.12[民108.12] |
頁 次 | 頁116-122 |
分類號 | 418.82 |
關鍵詞 | 自備藥; 預應式風險管理; HFMEA; Self-prepared medicine; Proactive risk assessment; |
語 文 | 中文(Chinese) |
中文摘要 | 目的:許多住院病人有使用自備藥的需求,所衍生出來的諸多用藥相關問題值得 注意,本研究旨在透過預應式風險管理手法改善自備藥管理,建立有效、安全的給藥 作業系統。 方法:本次研究應用 VA National Center for Patient Safety 之 HFMEA 步驟,就自 備藥品作業流程來繪出流程圖、進行危害指數評估、決策樹分析與找出失效原因提出 改善。 結果:依決策樹分析選出5 項需矯正流程,並依失效原因擬定5 項控制型行動對 策,如導入雲端藥歷進行改善,執行對策後重新評比危害指數,改善各項目之 RPN 均降至8 分以下;且整體成效總改善項目之危害指數由改善前74 分降低至31 分,下 降58%。自備藥品重複用藥比率逐漸下降,由改善前平均449 ppm 下降至改善後268 ppm。 結論:HFMEA 可以用來偵測以及校正醫療作業中潛在的風險,本次透過 HFMEA 手法,能有效改善自備藥品管理作業,提升病人的用藥安全。 |
英文摘要 | Objective: Many inpatients have the need to use self-prepared medicine, and the derived medicine-related problems are worth noting. This study aims to improve the management of self- prepared medicine through proactive risk assessment techniques and establish an effective and safe medicine management system. Methods: In this study, we applied Healthcare Failure Mode and Effects Analysis (HFMEA) to check the procedures of self-prepared medicine. And identified the cause of the failure model by graphically describing the process, conducting a hazard analysis, and using decision tree analysis. Results: We identified five steps in the model to be corrected. And drafted five control action strategies based on the findings. For example, using National Health Insurance Pharma Cloud System to improve this system. After implementing the strategies, every RPN score has fallen below 8 points and the total score of the hazard index dropped to 23 from 61, a 62-percent change. Conclusions: Healthcare Failure Mode and Effects Analysis (HFMEA) is a methodology for detecting and correcting such latent system errors in the health care setting. The utilization of HFMEA could improve the management of self-prepared medicine, and enhance the safety of medication administration. |
本系統中英文摘要資訊取自各篇刊載內容。