運用醫療失效模式與效應分析降低精神科住院病人異物哽塞發生率

Applying Healthcare Failure Mode and Effect Analysis to Reduce the Occurrence Rate of Asphyxia Caused by Objects for Hospitalized Psychiatric Patients

10.6847/TJPMHN.201512_10(2).0003

余文雯(Wen-Wen Yu)；黃宣宜(Xuan-Yi Huang)；王愛玲(Ai-Ling Wang)；賴吟香(Yin-Hsiang Lai)；陳惠君(Huei-Jian Chen)

醫療失效模式與效應分析 ； 精神科住院病人 ； 異物哽塞 ； Healthcare Failure Mode and Effect Analysis ； Hospitalized Patients of Psychiatry ； Asphyxia Caused by Objects

精神衛生護理雜誌

10卷2期（2015 / 12 / 01）

26 - 34

繁體中文

精神科住院病人出現異物哽塞，往往數分鐘內就會造成人命傷亡，其死亡率較一般人高出8倍。本院慢性精神病房2009年6月1日至2012年5月31日病人異物哽塞共13件，平均每年發生4.3件。運用醫療失效模式與效應分析（Healthcare FailureMode and Effect Analysis, HFMEA)，了解精神科住院病人進食過程潛在的風險，並針對11項進食流程可能的失效模式，執行預防措施及因應策略，包含修訂病人進食評估、餐點準備、餐點發放、備援人力調配、人員動線管理、用餐區域巡視及廚餘管理的標準作業流程，並完成人員教育訓練及進行各項流程稽核。本專案執行成果，住院病人異物哽塞發生率由平均每年4.3人降為0人。明顯可見醫療失效模式與效應分析，能有效降低病人異物哽塞風險，提升病人安全為首要的醫療照護品質。

When hospitalized psychiatric patients who have asphyxia caused by objects, they might meet their death in few minutes. Their death rate is higher than normal people by 8 times. From June 1, 2009 to May 31, 2012 in chronic psychiatry of the hospital, there were 13 cases of patients' asphyxia caused by objects. Averagely, every 4.3 cases happened every year. Through applying healthcare failure mode and effect analysis (HFMEA), this study aims to recognize the potential risk of hospitalized psychiatric patients in eating, and to improve 11 possible ineffective models of eating by preventive measures and responses, which include modification of patients' eating evaluation, food preparation, food distribution, allocation of supportive manpower, management of personnel's routes, inspection tour of eating area, SOP of kitchen waste management, personnel educational training and examination of processes. As to the executed result of this project, the occurrence of hospitalized patients' asphyxia caused by objects reduced from 4.3 people to 0 every year. Hence, it suggested that HFMEA should effectively lower patients' risk of asphyxia in eating, and patients' security should be viewed as the priority medical quality.

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