運用醫療照護失效模式與效應分析（HFMEA）提升手術病人安全與照護品質

Using Healthcare Failure Mode and Effect Analysis (HFMEA) to Improve Surgical Patient Safety and Care Quality

賴燕君(Yen-Chun Lai)；丁家羚(Jia-Ling Din)

病人安全 ； 醫療品質 ； 醫療照護失效模式與效應分析 ； 手術全期護理 ； patient safety ； medical quality ； failure mode and effect analysis of medical care ； perioperative nursing

先進工程學刊

15卷1期（2020 / 04 / 01）

27 - 31

繁體中文

手術室是高度專業化且高風險的部門，病人在手術過程中需仰賴醫護人員的專業、團隊合作及良好的環境及設施設備才能得到安全與品質兼具的照護。本研究運用醫療照護失效模式與效應分析（HFMEA）的結構性分析，以預防式系統風險管理介入手術病人安全及醫療品質管理。專案於2017.04.15至2017.12.31執行，依據HFMEA五大步驟執行，選出12項潛在失效模式、24項潛在失效原因，據以執行手術病人安全作業流程標準化、教學光碟影片錄製、教育訓練、制定及修改麻醉高風險與恢復室作業標準，定期稽核與策略推動。實施後，潛在失效原因由24項下降至1項，手術病人安全事件異常率由1.26%降為0.52%。透過整合醫療照護模式，讓相關醫療人員瞭解手術病人作業的認知與正確執行，提升醫療品質減少醫療事故，確實預防避免病人傷害，經由持續的系統監控，提供病人安全及手術全期照護品質。

The operating room is a highly specialized and high-risk department. Patients need to rely on the professionalism, teamwork, and good environment and facilities of medical staff during the surgical process to receive both safety and quality care. This study uses structural analysis of Healthcare failure mode and effects analysis (HFMEA) to preventive systemic risk management interventions for patient safety and medical quality management. The project was executed from 2017.04.15 to 2017.12.31. According to the five major steps of HFMEA, 12 potential failure modes and 24 potential failure causes were selected to perform the standardization of surgical patient safety operation procedures, teaching video recording, education training, formulation and Revised the operating standards of the high-risk anesthesia and recovery room, and regularly audited and promoted the strategy. After implementation, the potential failure causes decreased from 24 to 1, and the abnormal rate of safety events for surgical patients decreased from 1.26% to 0.52%. Through the integration of medical care mode, relevant medical personnel will be aware of the operation and awareness of the operation of patients during surgery, improve the quality of medical treatment, reduce medical accidents, and prevent and avoid patient injuries. Through continuous system monitoring, provide patient safety and the quality of care during surgery.

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