運用醫療失效與效應分析（HFMEA）提升住院病人用藥安全

Using Healthcare Failure Mode and Effect Analysis to improve inpatient medication safety

本研究目的在運用醫療失效模式與效應分析評估「住院病人用藥流程」潛在風險因子，並提出改善方案。HFMEA是目前運用於醫療流程的風險評估手法之一。透過流程的分析發現改善前有九項失效模式需加以改善，改善後各項模式皆有衡量控制方式，且住院用藥錯誤率由0.63%下降至0.11%。未來仍將持續加強同仁宣導，以落實用藥安全，為病人安全把關。增進病人安全需要團隊的努力，而此種具系統性及連續性的前瞻性風險分析方法，目的就是希望在危害尚未造成前，便可因流程改善而避免，可有效提高醫療品質及確保病人安全。

This study aimed to identify the potential risk factors of inpatient medication procedure by using the analytical tool of Healthcare Failure Mode and Effect Analysis (HFMEA). Besides that, this study will also provide recommended corrective actions by using HFMEA, which is one of the most popular assessment tools in identifying risk factors of medical procedure. There were 9 failure modes been identified by HFMEA procedure assessment; it also generates measurement and control strategies for every failure modes. After implementing corrective actions, the rate of inpatient medication error has significantly decreased from 0.63% to 0.11%. The evaluated hospital had set up medication safety guidance, which has been put into staff training program to ensure every employee have a better knowledge of patient safety. It takes a team’s effort to continuously improve patient safety, and HFMEA is a systematic, continuous and proactive risk analysis method to avoid damages from happening by finding potential pitfalls and doing procedure corrections. As the result, it could effectively improve the quality of healthcare and ensure patients’ safety.