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題 名 | 以預先防範手法建構化療安全管制=Applying Misenboushi Methods to Construct Safety Controls for Chemotherapy Sessions |
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作 者 | 鄭鈞任; 吳嘉興; 曾司旭; 藍晶玉; 謝永宏; | 書刊名 | 藥學雜誌 |
卷 期 | 36:1=142 2020.03[民109.03] |
頁 次 | 頁136-142 |
分類號 | 418.98 |
關鍵詞 | 預先防範型; 化療調配; 跡近疏失及錯誤; Mizenboushi method; Chemo-drug dispensing; Near-miss and error; |
語 文 | 中文(Chinese) |
中文摘要 | 背景:本院過去藉由醫療失效模式與效應分析 (healthcare failure mode and effect analysis, HFMEA) 品質改善程序已有效改善醫院的化療處方開立、調配和給藥流程作業,明顯提升癌症病人用藥安全。然而,當系統流程改善後,卻仍有跡近疏失 (near miss) 及錯誤 (error) 事件衍生。分析其原因主要係人為因素。 目的:導入預先防範型品質改善手法建立化療調配多重之安全管制,以降低藥品調配過程衍生跡近疏失及錯誤。 方法:運用預先防範型手法,依藥品調配通知、調配前準備、藥品調配及藥品調配後等四流程擬定改善對策。比較改善前後跡近疏失與錯誤發生率之差異。 結果:經由本次活動改善後,化療藥品調配跡近疏失及錯誤已明顯減少且風險優先指數 (risk priority number, RPN) 數值與等級已降低。 結論:結果顯示,運用預先防範型品管手法於化療調配作業可以有效減少調配疏失及錯誤產生,有效提升化療作業安全。 |
英文摘要 | Background: We have conducted procedures of HFMEA to improve the safety of chemotherapy sessions including prescribing, dispensing and administration. Some nearmisses and errors inevitably occurred even after HFMEA interventions. These events primarily caused due to human negligence. Purposes: Using the Mizenboushi methods to construct multiple safety controls for chemotherapy to reduce the occurrence of near-misses and errors. Methods: Applied the Mizenboushi methods to check procedures including ordering, pre-processing, preparation, and dispensing. Compared the differences before and after interventions. Results: After Misenboushi methods application, the near-misses and errors of chemotherapy sessions significantly reduced and the risk priority number (RPN) values and grades decreased. Conclusion: The results show that Mizenboushi methods were effectively applied in improving the safety of chemotherapy based on the decrease of the occurrence of near-misses and errors. |
本系統中英文摘要資訊取自各篇刊載內容。