運用醫療失效模式與效應分析工具提升輸血前置作業安全

Using Healthcare Failure Mode and Effect Analysis to Improve Blood Preparation Safety

醫療失效模式與效應分析是近年來醫界逐步推行的重要品管手法之一，JCAHO建 議每家醫院每年至少應進行一例醫療失效模式與效應分析品質改善活動，醫策會於新 制醫院評鑑條文中建議醫院應建立危機管理機制，運用危機預防處理模式分析以預防 危機事件發生。本文提出一例跡近錯誤的不良案件，利用醫療失效模式與效應分析備 血流程，以提供病人安全就醫環境。透過流程的分析發現改善前有十二項失效模式需 加以改善，改善後各項模式皆具有效衡量控制方式，同仁實際備血作業落實完整率由 71.4%進步至94.6%，改善成效顯著。未來仍將持續加強單位同仁的宣傳，以落實備血 的相關規定並持續監測備血作業安全性，為病人安全把關。

Healthcare Failure Mode and Effect Analysis (HFMEA) has becoming an important quality improvement method in the healthcare industry. The Joint Commission on Accreditation of Healthcare Organizations of United States suggested that hospital should conduct HFMEA on at least one high-risk process every year. This recommendation is also echoed by the Taiwan healthcare accreditation authority to list crisis management as a required accreditation item. Initiated by a near-miss adverse event, in this study we used HFMEA model to analyze the blood products preparation process in our hospital, with an aim to improve patient safety. Effective measurement and improvment strategies were development for all the 12 identified failure modes. The completeness of blood products preparation processes has significantly increased from 71.4% to 94.6%. We will continue to monitor the safety of blood transfusion processes based on the facts found from this HFMEA study.