運用醫療失效模式與效應分析（HFMEA）改善住院給藥作業品質

Using Healthcare Failure Mode and Effect Analysis (HFMEA) to Improve the Quality of Inpatient Medication Administration Process

本研究藉由運用醫療失效模式與效應分析（HFMEA）手法來檢視住院給藥作業流程，預測及探討潛在的失效模式和可能的影響結果，針對高風險項目提出改善對策進行改善，以提升住院給藥作業品質及用藥安全。小組成員討論和分析當前的住院給藥作業流程，建立主題的流程圖。檢討現行的住院給藥作業流程與高風險優先指數（RPN）≧8的問題，發現其中有51個潛在的故障原因和12個項目後，我們確定了20個故障模式。決策樹分析（DTA）確認改善的優先級故障模式有10個原因。分別是（1）STAT藥品領取時未簽收，（2）UD車藥品未即時核對確認，（3）藥品名稱相似，（4）藥品外觀相似，（5）醫令系統未能及時檢核提示錯誤處方，（6）高警訊藥品無獨立標籤，（7）藥品的冷運冷藏，（8）同成分不同劑量藥品辨識，（9）同成分不同劑型藥品辨識，（10）藥師專業能力不足。結果表明，經過三個月改善對策的執行後，再作改善後成效評估，發現改善後失效模式之RPN下降了73%、STAT藥品錯誤率由改善前的0.02%降為改善後的0.0035%，也降低護理站追蹤藥品的次數，此外還改善了藥師與護理人員之間的磨擦關係。醫療錯誤是一個嚴重的事件，往往會危害病人的生命安全。我們利用品管圈（QCC）的概念，選擇適當的品質控制方法，有效地減少醫療錯誤，並顯著提升病患的用藥安全。

The aims of the study were to review the high-risk projects to predict, explore the potential failure modes and possible impact of results, and develop actions and desired outcomes to improve the quality of Inpatient Medication Administration Processes (IMAP) using HFMEA technique in a regional hospital. The team members discussed and analyzed the current IMAP and developed a process map for the topic. We identified 20 failure modes after reviewing the current IMAP where there were 51 potential failure causes and 12 projects with high risk priority index (RPN≥8). There were 10 reasons for the failure modes with the priority of improvement confirmed by the decision tree analysis (DTA). They were as follow: (1) no sign for receiving STAT drugs (RPN=12). (2) no ready check-up for drugs in UD medication vehicles (RPN=12). (3) sound-alike drugs (RPN=16). (4) look-alike drugs (RPN=12). (5) no ready check-up in medication order system (RPN=8). (6) high-alert medications without independent labels (RPN=16). (7) drug was not well transferred (RPN=8). (8) drugs in different containing (RPN=9). (9) drugs in different dosage forms (RPN=9). (10) pharmacist was lacking in professional ability (RPN=8). The results showed the failure mode risk index declined 73% after three months. The rate of medication error for stat orders reduced from 0.02% to 0.0035%, and also reduced the number of tracking drugs from the nursing stations, in addition, also improved the relationship between nurses and pharmacists. Medication error is a serious events and often dangerous to patients. We took advantage of the Quality Control Circle (QCC) concept to select the appropriate quality control method to reduce medication errors effectively and significantly improved the medication safety of patients.