根本原因分析在醫療照護的應用

Application of Root Cause Analysis in Healthcare

10.6224/JN.54.6.77

徐宗福(Tsung-Fu Hsu)

根本原因分析 ； 失效樹分析 ； 病人安全 ； root cause analysis ； fault tree analysis ； patient safety

護理雜誌

54卷6期（2007 / 12 / 01）

77 - 83

繁體中文

本文在探討根本原因分析的定義、基本理念、主要目標、進行的步驟、最常用的失效樹分析、利益與方法學上限制等，並以某醫院所發生的醫療不良事件為例，加以失效樹分析之研究。根本原因分析為一種用來找出醫療意外或事件最基本或根本的因素或造成執行效能變異原因的程序。其基本理念是以系統改善為目的，而非將問題歸咎到個人身上。進行根本原因分析可分成四個階段：根本原因分析前的準備、找出近端原因、確認根本原因與設計及執行改善之行動計畫。失效樹分析乃由最上層至最基本特性去分析失誤原因以辨認可能根本原因與找出失誤機轉。進行根本原因分析，有利益與方法學上限制。最後，強調錯誤往往來自於不良的系統設計、作業流程及工作條件等，會誘使醫療從業人員製造出疏失或錯誤。藉由根本原因分析，去探究錯誤發生的根本原因與排除可能的系統失誤因素，跳脫將錯誤歸咎於個人的文化，以系統導向面對醫療疏失問題，建構一個實質的「以病人為中心之安全照護」的最優質就醫環境。

The main purpose of this study was to explore various aspects of root cause analysis (RCA), including its definition, rationale concept, main objective, implementation procedures, most common analysis methodology (fault tree analysis, FTA), and advantages and methodologic limitations in regard to healthcare. Several adverse events that occurred at a certain hospital were also analyzed by the author using FTA as part of this study. RCA is a process employed to identify basic and contributing causal factors underlying performance variations associated with adverse events. The rationale concept of RCA offers a systemic approach to improving patient safety that does not assign blame or liability to individuals. The four-step process involved in conducting an RCA includes: RCA preparation, proximate cause identification, root cause identification, and recommendation generation and implementation. FTA is a logical, structured process that can help identify potential causes of system failure before actual failures occur. Some advantages and significant methodologic limitations of RCA were discussed. Finally, we emphasized that errors stem principally from faults attributable to system design, practice guidelines, work conditions, and other human factors, which induce health professionals to make negligence or mistakes with regard to healthcare. We must explore the root causes of medical errors to eliminate potential RCA system failure factors. Also, a systemic approach is needed to resolve medical errors and move beyond a current culture centered on assigning fault to individuals. In constructing a real environment of patient-centered safety healthcare, we can help encourage clients to accept state-of-the-art healthcare services.