以醫療照護失效模式與效應分析促進輸血安全

Promoting Transfusion Safety by Failure Mode and Effects Analysis

輸血安全仰賴多單位的團隊合作與專業的判斷，為高風險醫療流程。人為疏忽即可能導致病人不可逆或永久性的傷害。台北某醫學中心回溯過去5年間，平均輸血跡近錯失約0.23％，不良事件0.001％。為進一步改善輸血作業的安全，我們運用HFMEA手法評估及探討輸血過程中可能錯誤的原因，並提出一系列方案來預防或降低錯誤。我們組成跨科部團隊，依輸血標準作業程序逐步分析，找出可能發生危機的原因或影響，進而導入必要的改善方法以及整合實驗室資訊系統與行動化的條碼系統設備等，從28項方案中最後採行了12個改善方法。導入改善方案後再重新評估，所有風險均下降，多個評量指標也持續進步，明顯改善了輸血安全。未來我們仍然會持續進行改善與系統性的監控管理。

The safety of blood transfusion depends on multidisciplinary teamwork and professional judgments. It is a high-risk process in medical practice. Even an unexpected error may result in inevitable or serious injuries of the patients. In a retrospective analysis of 5-year period in a medical center at Taipei, a near miss of 0.23% and adverse event of 0.001% per year were found. To further improve the safety of blood transfusion, we conducted a series of activities using Health Failure Modes and Effects Analysis (HFMEA) assessment. A multidisciplinary team was assigned to examine the standard transfusion procedures step by step, to review the causes and effects critically, and to implant improvement programs as needed, with the incorporation of laboratory information system and computerized mobile barcode equipment. Among 28 items, 12 were adjusted. In conclusion, a significant improvement of the safety of blood transfusion has been achieved. However, a continuous improvement and systemic monitoring is mandatory.