根因分析結合品質工具於護理實務之應用

Application of the Root Cause Analysis Combined with Quality Implement in Nursing Practice

根因分析(Root Cause Analysis, RCA)，係工業界常用的解決問題的邏輯程序，其根本的架構是屬於回應式(reactive)質化(qualitative)的處理分析技術，補充量化資料之不足，輔助掌握實際的情況與決定對策。1997年經美國的醫療機構評鑑單位(Joint Commission on Accreditation of Healthcare Organizations, JCAHO)的引用與推廣之下，才在醫療界受到重視與廣泛應用，RCA可以應用在臨床過程中的警訊事件(Sentinel)、不良事件(Adverse event)，甚至跡近錯失(Near Miss)事件。然而在醫療專業的領域中，各類醫療失誤的問題，常被輕易地判定為醫療專業人員個人的專業責任，而非以整體系統、團隊合作的方式來分析根因並解決問題。另外，又因近年來事件通報系統的推動，通報案件逐漸增多，RCA分析上出現瓶頸，不僅是人力不足，在原因分析與溝通上亦出現障礙，如何運用有限的人力，在既定的程序上以一個共通的工具平台進行討論，快速且準確地辨識事件發生之共同原因變異(Common cause variance)與特殊原因變異(special cause variance)，進而提出防範措施並回饋至照顧作業流程。本文的主要內容，即是以輸血錯誤案例說明RCA系統程序結合品質工具平台的分析作業模式，確認根因為：(1)輸血過程複雜；(2)溫血作業欠周詳；(3)溝通的障礙；(4)護理人員教育訓練不足等；再針對根因擬訂具體改善措施，避免事件再發生。期望運用此RCA案例與品質工具結合模式之介紹，提升醫療機構內人員應用RCA的普及與熟練度，進而提高人員對發生事件處理的速度，達到保障病人安全之目的。

The logical procedures of Root Cause Analysis (RCA) have been widely applied in the industry for accident investigation. The RCA was fundamentally a qualitative approach based on reactive process. Since RCA was strongly recommended by JCAHO (Joint Commission on Accredited of Health Organization) in 1997, it has been adopted and widely practiced in healthcare organizations to reflect clinical sentinel events, adverse events, and near-miss incidents. Although healthcare professionals should be responsible for negligence of medical practices in most cases; the problems of system integration and teamwork cooperation deserved further investigation. The reported number of incidents has increased due to the promotion of Incident Reporting System. Rapid and precise investigation under limited human resources with prompt feedback to the healthcare processes has become the major concern nowadays. The aim of this report is to introduce the advanced combination of RCA and quality implement tools and its benefits in nursing practice. The root causes of error occurred during blood transfusion included: (1) complicated SOP, (2) inapproprite SOP of warming blood, (3) communication barriers, and (4) insufficient nurses training. Solutions were made based on these root causes to avoid the further adverse events. As RCA structure is commonly practiced in medical environment, healthcare providers will be more familiar with this analysis. Such application is expected to increase the speed of handling adverse events and improve the safety of patient care.